William T. O'Donohue, Michelle R. Byrd, Nicholas A. Cummings, Deborah A. Henderson - Behavioral Integrative Care - Treatments That Work in The Primary Care Setting (2004) PDF

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C M Y CM MY CY CMY K
BEHAVIORAL
INTEGRATIVE
CARE
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C M Y CM MY CY CMY K
BEHAVIORAL
INTEGRATIVE
CARE
Treatments that work in the primary care setting
Edited by
William T. O’Donohue
Michelle R. Byrd
Nicholas A. Cummings
Deborah A. Henderson
NEW YORK AND HOVE

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Published in 2005 by
Brunner-Routledge
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New York, NY 10016
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Copyright © 2005 by Taylor & Francis Group, a Division of T&F Informa.
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Printed in the United States of America on acid-free paper.
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All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic,
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10 9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data

Behavioral integrative care : treatments that work in the primary care setting / editors, William T. O’Donohue … [et al.].
p. ; cm.
Includes bibliographical references and index.
ISBN 0-415-94946-7 (hardback : alk. paper)
1. Mental health services—United States. 2. Integrated delivery of health care—United States. 3. Primary care
(Medicine)—United States.
[DNLM: 1. Mental Disorders—therapy. 2. Delivery of Health Care, Integrated. 3. Mental Health
Services—organization & administration. 4. Primary Health Care—methods. WM 400 B419 2004] I. O’Donohue,
William T. II. Title.
RA790.5.B366 2004
362.1’068—dc22 2004011580
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Contents
About the Editors ix

Contributors xi
Preface xvii
Introduction The Case for Integrated Care: Coordinating Behavioral

Health Care With Primary Care Medicine 1
Michelle R. Byrd, William T. O’Donohue, and
Chapter 1 Training Behavioral Health and Primary Care Providers for

Integrated Care: A Core Competencies Approach 15
Kirk D. Strosahl
Chapter 2 Adapting Empirically Supported Treatments to the Primary

Care Setting: A Template for Success 53
Patricia Robinson
Chapter 3 The Role of the Behavioral Health-Care Specialist in the

Treatment of Depression in Primary Care Settings 73
Glenn M. Callaghan and Jennifer A. Gregg
Chapter 4 Anxiety Disorders in Primary Care 87

Laura Campbell-Sills, Jessica R. Grisham, and Timothy A. Brown
Chapter 5 Suicide and Parasuicide Management in the Primary Care Setting 109
Elizabeth A. Lillis and Alan E. Fruzzetti
Chapter 6 Integrating PTSD Services: The Primary Behavioral

Health Care Model 129
Gregory A. Leskin, Leslie A. Morland, and Terence M. Keane
v
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vi • Contents
Chapter 7 Identification and Treatment of Substance Abuse in

Primary Care Settings 143
Janet L. Cummings
Chapter 8 Identifying and Treating the Somatizer: Integrated Care’s

Penultimate Behavioral Intervention 161
Chapter 9 Treating Attention Deficit Hyperactivity Disorder and

Oppositional Defiant Disorder in the
Primary Care Setting 177
William E. Pelham, Jr., David Meichenbaum, and Gregory A. Fabiano
Chapter 10 Providing Integrated Care for Smoking Cessation 201

Elizabeth V. Gifford, Kathleen M. Palm, and Andrea Diloreto
Chapter 11 Infertility 221

Negar Nicole Jacobs
Chapter 12 The Integration of Psychosocial Interventions

Into the Oncology Practice 237
Adrienne H. Kovacs and Arthur C. Houts
Chapter 13 Managing Obesity in Primary Care 253

Mark W. Conard, Walker S. Carlos Poston, and John P. Foreyt
Chapter 14 As Precise as the Scalpel’s Cut … Sort of: Psychological and

Self-Regulation Treatments in Preparation for Surgery and
Invasive Medical Procedures 273
Rodger S. Kessler
Chapter 15 Assessment and Treatment of Chronic Benign Headache

in the Primary Care Setting 293
John G. Arena and Edward B. Blanchard
Chapter 16 Addressing Chronic Pain in Primary Care Settings 315

Richard C. Robinson, Margaret Gardea, Ann Matt Maddrey, and
Robert J. Gatchel
Chapter 17 Psychosocial Interventions With Type 1 and 2

Diabetes Patients 329
Glenn M. Callaghan, Jennifer A. Gregg, Enrique Ortega, and
Kristoffer S. Berlin
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Contents • vii
Chapter 18 Increasing Medication Adherence in Chronic Illnesses:

Guidelines for Behavioral Health-Care Clinicians
Working in Primary Care Settings 347
Eric R. Levensky
Chapter 19 The Integrated Management of Adult Asthma 367

Michelle R. Byrd, Kyle E. Ferguson, Deborah A. Henderson,
Erin M. Oksol, and William T. O’Donohue
Index 383
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About the Editors
William T. O’Donohue, Ph.D., earned his doctorate in clinical psychology at SUNY–Stony Brook
and a master’s degree in philosophy from Indiana University. He is the Nicholas Cummings Profes-
sor of Organized Behavioral Healthcare Delivery in the Department of Psychology at the University
of Nevada–Reno, where he also holds adjunct appointments in the Departments of Philosophy and
Psychiatry. He is also currently the president and CEO of the University Alliance for Behavioral
Care, Inc., a company providing integrated-care services. In addition to this book, he is editor and
coeditor of a number of other volumes including Management and Administration Skills for the
Mental Health Professional, Behavioral Health as Primary Care, The Impact of Medical Cost Offset on
Practice and Research, and Early Detection and Treatment of Substance Abuse Within Integrated Pri-
mary Care.
Michelle R. Byrd, M.A., is an assistant professor in the Department of Psychology at Eastern Mich-
igan University. Her research interests include pediatric primary care integration and the incorpo-
ration of acceptance strategies in the treatment of medically ill populations.
Nicholas A. Cummings, Ph.D., Sc.D., is a distinguished professor in the Department of Psychology

at the University of Nevada–Reno and president of the Cummings Foundation for Behavioral
Health. He is chairman of the board of the University Alliance for Behavioral Care and the Nicholas
and Dorothy Cummings Foundation. He is the founder of over two dozen organizations including
the California School of Professional Psychology, American Biodyne, and the National Academies
of Practice. He is a past president of the American Psychological Association and a recipient of the
gold medal for a Lifetime of Achievement in Practice. He is the author of over 400 journal articles
and book chapters and has authored or coedited 30 books.
Deborah A. Henderson, M.S., is a doctoral candidate in clinical psychology at the University of

Nevada–Reno. She is the author of several journal articles and book chapters and is currently
completing her predoctoral internship at the Reno Veterans Administration Medical Center.
ix
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Contributors
John G. Arena, Ph.D., is lead psychologist at the Augusta Department of Veterans Affairs Medical
Center and professor of psychiatry and health behavior at the Medical College of Georgia–Augusta.
He is widely published in the area of psychological assessment and treatment of chronic pain
disorders, with his major emphasis being headache and lower back pain.
Kristoffer S. Berlin, M.S., received his B.A. from the University of California–Santa Cruz and is cur-
rently completing his doctoral degree in clinical psychology from the University of Wisconsin–
Milwaukee. His research interests include behavioral pediatrics, pediatric/health psychology, and
utilizing functional analytic psychotherapy, and acceptance and commitment therapy approaches
with parents and individuals with medical conditions.
Edward B. Blanchard, Ph.D., is distinguished professor of psychology at SUNY–Albany and is an

internationally recognized expert in the area of headache and behavioral medicine. He has pub-
lished widely and held numerous federally funded grants in the areas of headache, posttraumatic
stress disorder, and hypertension. He is director of the Center for Stress and Anxiety Disorders at
the University at Albany, and he has received numerous accolades in his long career, including the
distinguished scientist award from the Association for Applied Psychophysiology and Biofeedback.
Timothy A. Brown, Psy.D., is a research professor of psychology at Boston University and director
of research of the Center for Anxiety and Related Disorders. He currently serves as associate editor
of the Journal of Abnormal Psychology and Behavior Therapy. He was a member of the DSM-IV and
DSM-IV-TR Anxiety Disorders Workgroups, and he is currently an executive member of the DSM-
V Research Planning Committee. His NIH-supported research is focused on the classification,
nature, and course of anxiety and mood disorders.
Glenn M. Callaghan, Ph.D., received his doctoral degree in clinical psychology from the University
of Nevada. Currently, he is associate professor and director of clinical training for the Master
of Science in Clinical Psychology Program at San Jose State University. His research interests are in
the areas of psychosocial interventions in primary care, alternative approaches to psychological assess-
ment and classification, and research on interpersonal psychotherapies, including Functional Analytic
Psychotherapy.
xi
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xii • Contributors
Laura Campbell-Sills, Ph.D., received her doctorate in clinical psychology from Boston University.
Her research is focused on factors that may affect the development, course, and manifestation of
anxiety and mood disorders. She is currently a postdoctoral fellow at the University of California–
San Diego.
Mark W. Conard, M.A., is a doctoral student in the clinical health psychology program at the Univer-
sity of Missouri–Kansas City and supervising research assistant at the Mid-America Heart Institute.
He is also a licensed professional counselor. His research interests include cardiovascular health
outcomes and psychosocial issues in organ transplantation.
Janet L. Cummings, Psy.D., received her doctorate in clinical psychology from Wright State University
School of Professional Psychology and is a licensed psychologist in the state of Arizona. In addition,
she is currently an adjunct professor in the Department of Psychology at the University of
Nevada–Reno, and she frequently provides workshops for mental health professionals throughout
the United States and Europe. With over 15 years of clinical experience and particular expertise in
the area of substance abuse, she has authored six books as well as numerous journal articles and
book chapters.
Andrea Diloreto, M.A., is an advanced graduate student in the clinical psychology training pro-
gram at the University of Nebraska–Lincoln. Her research interests are primarily in the area of child
maltreatment, with particular emphasis on the long-term psychosocial, behavioral, and physical
correlates of various types of abuse.
Gregory A. Fabiano, M.A., is a clinical psychology graduate student at SUNY–Buffalo. Current

research interests include studying effective behavioral and combined behavioral and pharmacolog-
ical treatments for children with ADHD.
Kyle E. Ferguson is a doctoral student in clinical psychology at the University of Nevada–Reno.

He earned a master’s degree in behavior analysis from Southern Illinois University. His research
interests include managed behavioral health care and, in particular, medical cost offset. In addition
to other publications, he has coauthored two books and coedited three recent volumes.
John P. Foreyt, Ph.D., is a professor in the Department of Medicine, Baylor College of Medicine,
Houston, Texas, and director of the Baylor DeBakey Heart Center’s Behavioral Medicine Research
Clinic. His research interests include the development of behavioral strategies for the reduction of
cardiovascular risk factors, including obesity, hypertension, diabetes, and dyslipidemia. He has
published more than 260 articles and 17 books in these and related areas.
Alan E. Fruzzetti, Ph.D., is associate professor of psychology and director of the Dialectical Behav-
ior Therapy (DBT) and Research Program at the University of Nevada–Reno. He received his Ph.D.
from the University of Washington. His research focuses on the interplay between psychopathology
and couple and family interactions, and the development of effective treatments for these problems.
He is research advisor and member of the board of directors of the National Education Alliance for
Borderline Personality Disorder; he maintains a clinical practice with individuals and families; and
he has provided extensive training in the United States, Europe, and Australia in DBT with individ-
uals, couples, and families.
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Contributors • xiii
Margaret Gardea, Ph.D., conducted her dissertation research at the University of Texas Southwestern
Medical Center–Dallas, and is currently in private practice in El Paso, Texas.
Robert J. Gatchel, Ph.D., ABPP, is a professor in and chair of the Department of Psychology at the
University of Texas–Arlington.
Elizabeth V. Gifford, Ph.D., is a research scientist at the Center for Health Care Evaluation, Depart-
ment of Veterans Affairs and Stanford University Medical Centers. Her interests include smoking
cessation and tobacco control, social context and coping, and health-care practices, policy, and
evaluation.
Jennifer A. Gregg received her Ph.D. in clinical psychology at the University of Nevada. She cur-
rently works as an education coordinator at the Palo Alto VA Health Care System. Her research
interests are diverse, and they include application of Acceptance and Commitment Therapy to
medical populations and the role of avoidance in PTSD, chronic illness, and other co-morbid con-
ditions. She also conducts research and writes in the areas of the dissemination and implementa-
tion of effective interventions and the detection and treatment of mental health problems in
primary care settings.
Jessica R. Grisham is a doctoral candidate in clinical psychology at Boston University. She received
her B.A. in English and psychology from University of Pennsylvania and her M.A. from Boston
University. Her current research interests include personality and neuropsychological characteris-
tics contributing to the co-morbidity of various mood and anxiety disorders, diagnostic issues
related to obsessive-compulsive disorder, and the etiology and treatment of compulsive hoarding.
Arthur C. Houts, Ph.D., is professor emeritus and former director of clinical training at the Univer-
sity of Memphis. He currently sees patients and conducts research at West Clinic, a leading commu-
nity oncology center in Memphis, Tennessee. He is interested in assessing and improving quality of
life in cancer patients by using knowledge from empirically supported psychological interventions.
Negar Nicole Jacobs, Ph.D., earned her doctorate in clinical psychology at the University of
Nevada–Reno. She is currently a staff psychologist at the Veterans Administration Sierra Nevada
Health Care System in Reno. Her primary research area is in the area of integrated care with an
emphasis on the psychological factors in infertility treatment.
Terence M. Keane, Ph.D., is professor and vice chairman of research in psychiatry at the Boston
University School of Medicine. He is also the chief of psychology and the director of the National
Center for PTSD at the VA Boston Healthcare System. The past president of the International
Society for Traumatic Stress Studies, he has published six books and over 160 articles on the assess-
ment and treatment of PTSD.
Rodger S. Kessler, Ph.D., is a clinical health psychologist practicing in family medicine at Berlin
Family Health in Montpelier, Vermont. He is on the staff at Central Vermont Medical Center where
he is chair of the quality management committee and a member of the credentials and contracts
committees. His current research focuses on patient compliance with psychological referral in
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xiv • Contributors
integrated practice and the impact of integrated medical psychological care on medical and cost
outcomes. He is a fellow of the American Psychological Association and is also past president of the
Vermont Psychological Association.
Adrienne H. Kovacs, Ph.D., is currently a postdoctoral fellow at the University Health Network in
Toronto, Canada. Her focus is the enhanced quality of life of cardiac patients and the promotion of
healthy lifestyle behaviors. She provides clinical services to cardiac patients and is currently con-
ducting several research projects with this population.
Gregory A. Leskin, Ph.D., is a health research scientist at the National Center for PTSD, VA Palo
Alto Health Care System. He chairs the National Center for PTSD initiative to increase integrative
behavioral health models of care into VA primary care settings.
Eric R. Levensky, M.A., is a doctoral candidate in clinical psychology at the University of

Nevada–Reno. The author of several journal articles and book chapters, he is currently conducting
a randomized, controlled trial evaluating a behavioral intervention to promote treatment adher-
ence in HIV patients.
Elizabeth A. Lillis, M.A., is currently a doctoral student at the University of Nevada–Reno. She
received her B.A. from the University of California–San Diego. Her research interests include cou-
ple and family interactions, dialectical behavior therapy (DBT), psychotherapy outcome, brief
interventions, and crisis management.
Ann Matt Maddrey, Ph.D., is the director of consult liaison psychiatry and behavioral medicine at
the University of Texas Southwestern Medical Center–Dallas.
David Meichenbaum, M.A., is a doctoral candidate at SUNY–Buffalo. His current research interests
include studying effective treatments for children and adolescents with ADHD and exploring the
impact of prolonged stimulant medication use on later life functioning.
Leslie A. Morland, Psy.D., is a health research scientist at the National Center for PTSD–Pacific
Island Division in Honolulu, Hawaii, and an assistant clinical professor in the Department of
Psychiatry in the John Burns School of Medicine at the University of Hawaii.
Erin M. Oksol, Ph.D., earned her doctoral degree in clinical psychology at the University of
Nevada. She is currently an outpatient therapist at Children’s Behavioral Services in Reno. Her
research interests include behavioral pediatrics and improving compliance with pediatric diabetic
treatment regimens.
Enrique Ortega is a doctoral student at the University of Southern California in health behavior
research. Enrique received his B.A. in psychology from San Jose State University. Currently he is
studying the effects of subcultures on smoking (for the Transdisciplinary Tobacco Use Research
Center) and the effects of ethnic categorization on tobacco use statistics. His primary interest is in
chronic disease management in cancer.
Kathleen M. Palm, Ph.D., completed her doctorate in clinical psychology at the University of
Nevada–Reno. She is currently a postdoctoral fellow at Brown Medical School. Her current research
interests include smoking cessation and treatment development for substance use disorders.
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Contributors • xv
William E. Pelham, Jr., Ph.D., is professor of psychology, pediatrics, and psychiatry and director
of the Center for Children and Families at SUNY–Buffalo. His summer treatment program for
ADHD children has been recognized by the American Psychological Association as a model pro-
gram and is widely recognized as the state-of-the-art in treatment for ADHD. He has authored or
coauthored more than 200 professional papers dealing with ADHD and its treatment.
Walker S. Carlos Poston II, Ph.D., M.P.H., FAHA, received his Ph.D. from the University of California–
Santa Barbara. He is currently an associate professor at the University of Missouri–Kansas City
Clinical Health Psychology Program and School of Medicine, associate chair of the Department of
Psychology, and codirector of behavioral cardiology research at the Mid-America Heart Institute at
Saint Luke’s Hospital. He is a fellow of the North American Association for the Study of Obesity, the
American Heart Association Council on Epidemiology and Prevention, and the Council on Nutri-
tion, Physical Activity, and Metabolism, and a cardiovascular health fellow alumnus of the Ameri-
can Hospital Association’s Health Forum. He has published over 120 peer reviewed journal articles
and book chapters on the etiology, assessment, and management of obesity and eating disorders.
Patricia Robinson, Ph.D., provides consultation and training services in primary care behavioral
health integration for Mountainview Consulting Group, Inc. She is also a clinical supervisor and
clinical provider for Yakima Valley Farm Workers Clinic system in Washington state and Oregon.
She worked as a clinical and research psychologist at Group Health Cooperative of Puget Sound for
15 years. She is the author of two books and many book chapters and articles.
Richard C. Robinson, Ph.D., is an assistant professor at the University of Texas Southwestern

Medical Center–Dallas.
Kirk D. Strosahl obtained his Ph.D. in clinical psychology from Purdue University. In more than a
decade of clinical practice in primary care, he has worked as a practicing clinician for 11 primary
care teams and over 150 primary care providers, including adult medicine providers, OB-GYN phy-
sicians, and pediatricians. He has written numerous articles on the subject of primary care behav-
ioral health integration and has presented workshops on the subject both regionally and nationally.
He currently is research and training director for Mountainview Consulting Group, Inc., a firm
specializing in providing consultation and training for health-care systems that are attempting to
integrate primary care and behavioral health service lines.
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Preface
We decided to compile this book because we thought it would be useful for clinicians and researchers
who are a part of, or want to become a part of, an important emerging trend in health-care
delivery: integrated care. There are several reasons to believe that in many cases health care
delivered by a multidisciplinary team of medical and behavioral health providers is better
than health-care delivery that is disjointed or delivered by providers who are not functioning as a
collaborative unit. By “better” we mean treatment that is both more effective and efficient. Specifi-
cally, integrated care envisions treatment that better fits with what the patient actually needs and
thus leads to more adequate service delivery, healthier patients, and increased patient and provider
satisfaction. In addition, particularly in an era of a major health-care crisis, integrated care has the
potential, in the long term, to be more cost efficient.
However, many providers do not have the skill sets to deliver integrated care. To address the gap
between training and the demands of practice, there are two obvious strategies. First, new providers
in the field must be trained to function competently in an integrated-care environment. For the
past 5 years at the University of Nevada–Reno, we have attempted to prepare new clinicians for
the particular demands of functioning in an increasingly managed and integrated-care environ-
ment through innovative courses and practicum experiences. However, by providing a new model
for training scientist-practitioners in the field of psychology, we are succeeding only in changing
the skills of new professionals, leaving existing psychologists in the field still unprepared for the
integrated-care environment. Therefore, a second strategy to bridge training- and practice-
demands must serve to supplement the training of existing providers. This book is aimed at reach-
ing both trainees and seasoned professionals with the overarching goal of improving care for our
clients, present and future.
Here we will introduce behavioral clinicians to the overall ecology of primary care (e.g., fast-paced,
oriented more toward action, acute problem solving, population management, stepped care,
and, obviously, physical complaint resolution). In addition, this book will attempt to teach specific
skill sets related to the assessment and treatment of particular types of problem presentations as
they occur in primary care settings, so that behavioral health providers will be aware of and better
prepared for their potential role in this environment. Thus, the book addresses assessment and
treatment strategies that are effective in the primary care setting, as presented by known experts
in each subfield.
In summary, based on current trends in the research literature and the practice marketplace,
we believe the inclusion of behavioral health care in medical settings is an important development
that makes both clinical and financial sense. We are concerned that one impediment to its growth
xvii
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xviii • Preface
may be that training-program leaders do not have sufficient access to relevant training materials
and are not retooling fast enough to provide the health-care economy with well-trained clinicians
and researchers. There are some key exceptions to this; we hope there will be a trend in training to
keep pace with the inclusion of multidisciplinary teams in practice settings. We hope this book will
become a seminal text in training future scientist-practitioners.
We have many people to thank for this book. First, we would like to thank our publisher,
Brunner-Routledge. In particular, we are grateful for the patience and support of our editors,
Dr. George Zimmar and Mr. Dana Bliss. We would also like to thank Nanci Fowler and Sara Ashby
for their administrative assistance. Finally, we would like to thank each chapter author for his or her
ability to think in novel ways while applying high standards and outstanding scholarship.
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Introduction
The Case for Integrated Care: Coordinating
Behavioral Health Care With Primary
Care Medicine
MICHELLE R. BYRD, WILLIAM T. O’DONOHUE, AND

NICHOLAS A. CUMMINGS
Behavioral health care in 2004 bears little resemblance to the not-so-distant days of burgeoning
private practices, limitless sessions of psychotherapy, and the work of the psychologist occurring
more or less independently. In the past two decades, health-care funding has undergone a veritable
systemic revolution resulting in significant and seemingly permanent changes in the field of clinical
psychology, with traditional models of practice and financial viability rapidly changing. Although
psychologists and other mental health-care providers cannot bend at the will of economic contin-
gencies alone, they also cannot deny the realities of current reimbursement practices and related
limited access to mental health services. These changes in the marketplace call upon behavioral
health providers to cultivate innovative models of care.
The purpose of this book is to provide an overview of what may become the new standard of
mental health-care provision—the integration of behavioral and medical care. In this introductory
chapter, we provide some context in which to best understand models of integration, to explore the
rationale for integrated models, to operationally define forms and functions of integrated care, as
well as describe how we have conceptualized this book.
The Context of Integrated Care

As a consequence of what has been called a “health-care crisis” in America, mental health care
appears to be especially hard hit by reimbursement cuts and limits on services, perhaps because
mental health care has long been viewed by legislators and third-party payers as secondary
to medical/surgical care. Although health-care expenditures continue to rise exponentially, with
$1.4 trillion spent in 2002 (14% of the GDP) and expected growth of 7.3% each year in the next
decade, only a small proportion of these funds is earmarked for mental health care. For example, in
1996, of the $943 billion spent on health care in the United States, only 7% was devoted to mental
health care, with another 1% devoted to addictive disorders and 2% to dementia/Alzheimer’s
1
2 • Behavioral Integrative Care
disease. Clearly, the apportioning of dollars, at least in part, represents the value placed on mental
health care by decision-making bodies.
As this book goes to press, the largest “carved-out” managed behavioral health-care organiza-
tion, Magellan Health Services, is in bankruptcy. Its stock has dropped from a high of $30 per share
to nearly zero. More changes are on the horizon as the health-care carve-out industry attempts to
deal with its serious financial problems. However, rather than spelling the end of clinical psychology,
in many ways economic uncertainty has actually pushed the science and practice of our discipline
beyond historical parameters. With the trends toward increasingly managed and empirically driven
care, new models of practice have begun to emerge for clinical scientist-practitioners.
Today at least a part of clinical decision making has been externalized to third-party gatekeepers
(through means such as preauthorization of sessions and utilization review), who may not have
sufficient training to make clinical decisions and who must form opinions based on limited under-
standing of specific cases. For many data-oriented clinicians, the current contingencies governing
practice may not be too different from their traditional emphasis on providing efficient and effec-
tive treatment for their clients. For practitioners who were not basing their clinical decisions on the
empirical literature, the mandated changes in service delivery may be cause for, at minimum, a
reorientation of their practice, retraining, or even a career change or early retirement. Integrated
care provides a means of restructuring clinical practice so as to maximize existing human and
financial resources.
Defining Integrated Care

Integrated care is a term with many meanings, which can vary according to what is integrated (dental,
nutrition, alternative medicine, etc.) as well as the extent to which a particular system is integrated
(ranging from more screening and referral to collocation to integrated medical management
groups). Though integrated care can be defined in many ways, we conceptualize it as the process
and product of medical and mental health professionals working collaboratively and coherently
toward optimizing patient health through biopsychosocial modes of prevention and intervention.
Integrated care, then, cannot be defined by one type of service or one type of setting. The primary
function of integration remains constant, but the system may actually take many forms. One way to
understand the topography of integrated care is to classify systems based on their level of integra-
tion between medical and mental health care. The level of integration is a way of describing the
degree to which services are provided collaboratively by a multidisciplinary team of clinicians.
O’Donohue, Cummings, & Ferguson (2003) provide the graphic in Figure I.1 to illustrate the con-
tinuum of integrated care.
As described above, although integrated care may differ in terms of level of integration, the func-
tion and related goals of integrated systems remain constant. Some of these treatment targets are
the same as or consistent with goals articulated in traditional models of care; however, integrated
models also have the potential to broaden the scope of practice. Specifically, integrated care has the
following aims:
1. Improved recognition of behavioral health needs in medical settings.

2. Improved collaborative care and management of patients with psychosocial issues in
primary care.
3. Increased availability of an internal resource for primary care providers to help address
patients’ psychosocial concerns or behavioral health issues and provide rapid feedback to
the provider, without referring to a specialty mental health clinic.
4. Improved fit between the care patients seek in primary care and the services delivered.
The Case for Integrated Care • 3
High
Integration
(population-
based)
Mid-Point
Integration
Low
Integration
(1-800 phone
number to behavioral
health specialist)
Integration can occur at any point in the continuum of intensity, depending on customer readiness and. market receptivity
Fig. I.1 Continuum of integrated care (from O’Donohue, Cummings, & Ferguson, 2003, p. 38).
5. Prevention of more serious behavioral and physical health problems through early recogni-
tion and intervention.
6. Triage when appropriate, into more intensive specialty health care by the behavioral health
consultant.
As described above, integrating a system of care is no small task—a team effort is required. Inte-
grated care is inherently collaborative and multidisciplinary, as a close working relationship
between all care providers is essential for the model to be successful. In the integrated care model,
medical health professionals, such as physicians, nurses, and nurse practitioners, serve as the
primary referral sources for behavioral care providers (BCPs), ideally located onsite. Behavioral
care providers may be clinical psychologists, psychiatrists, or master’s level clinicians with special-
ized training in primary care.
In most models of integrated care, behavioral services are delivered in the primary care setting.
Primary care is defined as the medical setting in which patients receive most of their medical care,
most frequently staffed by a general practitioner or family practice physician. By definition, then,
primary care is the first source patients look to for treatment. Primary care is distinguished from
specialty care, wherein patients receive care by more highly trained providers such as cardiac or
mental health specialists.
In the integrated care model, when, in the course of a routine medical visit, a medical profes-
sional notices that the patient may be presenting with psychological symptoms, he or she may
invite the BCP into the visit to provide immediate assessment and possible brief treatment for the
psychological sequalae. In doing so, the patient has the opportunity to receive seamless care more
coherently addressing all of the presenting problems, rather than artificially compartmentalizing
his or her physical and psychological complaints. Furthermore, patients do not suffer any
additional delay in receiving treatment necessitated by the referral process, nor do they incur the
stigma of being referred to the mental health sector for treatment.
There are four main types of problems targeted in an integrated care model. First, integrated care
directly targets psychological problems, such as anxiety and depression, which may be presented in the
primary care setting. Patients may complain of symptoms such as sleep or appetite disturbance, irrita-
bility, or marital/family problems. The diagnosis of psychological disorders in primary care is given by
BCPs based on the referral of medical professionals who are primarily responsible for the patient’s care.
Second, problems that include both physical and psychological components are explicitly
targeted in integrated models of care. These problems include substance abuse (drugs, alcohol,
nicotine) and are often identified in routine primary care assessment. However, in traditional
models of care, treatment of co-morbid problems is unlikely to occur in the primary care setting,
thereby creating a chasm between identification and treatment of the problem behavior into which
the patient is likely to fall.
Not only is there an apparent need for the recognition and treatment of behavioral health prob-
lems as independent entities in primary care as described above, but behavioral issues also play a
key role in the development, detection, and successful treatment and management of primary medi-
cal disorders. Therefore, integrated care aggressively targets psychological components of physical
illnesses, both acute and chronic. Many relationships between both acute and chronic physical
disorders and secondary behavioral processes have been empirically established (cardiac disease
and hostility; panic and asthma, etc.). Chronic illnesses with identifiable psychological components
that may contribute to the development or exacerbation of physical symptoms include coronary
artery disease, arthritis, and asthma. Depending on the specific variables in question, psychological
processes may be conceptualized as either components of the cause or effects of physical processes.
Indeed, a transactional model may also be appropriate in many cases.
Finally, integrated care models also address nonspecific factors related to both acute and chronic
illness states that account for a substantial proportion of treatment failure and increased medical
costs. These factors include stress, noncompliance with regimens, subclinical mood or anxiety
disorders, coping styles, personality characteristics, sociodemographic factors, social support
factors, sleep, and dietary considerations.
How Is Integrated Care Different from Psychological Practice Already Occurring in Medical Settings?
Although the relevance of psychological issues in the assessment and treatment of medical patients
has long been recognized, the participation of psychologists in this process is relatively novel.
For the informed reader, however, integrated care will obviously appear to be an extension of
two already existing areas of practice—behavioral medicine and consultation-liaison psychiatry.
Behavioral medicine is commonly defined as “the interdisciplinary field concerned with the devel-
opment and integration of behavioral and biomedical science, knowledge and technique relevant to
health and illness and the application of this knowledge and these techniques to prevention,
diagnosis, treatment, and rehabilitation” (Schwartz & Weiss, 1978, p. 250, as cited in Belar &
Deardorff, 1995, p. 2).
Although we acknowledge that a fundamental competency in behavioral medicine is a prerequi-
site for practicing in an integrated care environment, it is not sufficient. Behavioral medicine, while
collaborative in nature, is typically practiced in specialty mental health settings following the referral
of the treating physician. Behavioral medicine specialists, then, serve more the function of a
consulting provider than a treatment team member, as in integrated models. Furthermore, many
behavioral medicine providers have built their practices around particular groups of patients
or diagnoses (e.g., pulmonary patients), whereas integrated care requires a greater breadth of
knowledge and skills to treat more medically diverse primary care populations. Integrated care differs
from traditionally practiced behavioral medicine in that it requires collaboration at the logistic and
theoretical levels, which exceeds that required for the practice of behavioral medicine alone.
More closely resembling integrated care is the discipline of consultation-liaison (C-L) psychiatry.
The field of C-L psychiatry has long been in the business of providing mental health service within
medical settings, albeit with historically different targets and strategies than are being discussed in
this text. Thus, the C-L literature provides a strong foundation on which to base new models of
integrated care. C-L has traditionally been the link between psychiatry and the rest of medical
practice, providing two primary services. First, C-L services provide direct patient care for psychiatric
problems in medical settings (consultation), a form of behavioral medicine. Second, C-L services
also provide indirect care by educating and consulting with primary care teams on the appropriate
care of patients with co-morbid psychiatric conditions (liaison). Although the development of
integrated models of care in psychological practice is relatively new, C-L psychiatry has been in
practice and been actively studied since the 1970s.
Although C-L literature is a useful springboard for building understanding of integrated models
of care (see Stern, Fricchione, Cassem, Jellinek, & Rosenbaum, 2004 for an excellent reference.),
there are several ways in which C-L psychiatry differs from the models we suggest in this book.
First, C-L psychiatry is by definition the domain of medical doctors whose training and expertise
differ drastically from the classic training of other (non-MD) mental health professionals. As such,
the C-L literature assumes a level of understanding of disease processes and an overall orientation
toward the medicalization and pharmacological treatment of psychological disorders. In addition,
C-L psychiatry has been developed in hospital settings. Although we support the integration of care
for medical inpatients, we also assert that behavioral care is imperative in outpatient care, including
both primary and specialty care clinics. Finally, C-L psychiatry is more focused on the task of
assessment within the medical setting and referral for follow-up in specialty psychiatric clinics
when warranted, with limited emphasis on treatment. So, even though the practices of traditional
behavioral medicine and C-L psychiatry undoubtedly provide the foundation for integrated care,
integrated care is a unique model with unique advantages and challenges.
Rationale for Integrated Care Model

Integrated care appears to offer a number of advantages over traditional models of providing medical
and mental health care independently and has, therefore, been proposed as a primary area of expan-
sion in psychological research and practice (Cummings, O’Donohue, Hayes, & Follette, 2001).
Integrated Care Treats Psychological Disorders Where Treatment Is Sought

First, primary care is already the de facto arena in which mental health services are provided. Statis-
tically, the majority of patients who meet DSM-IV diagnostic criteria see their primary care physi-
cians at minimum once per year and receive psychological services more often during their primary
care visits than from specialty mental health-care providers (Reiger et al., 1993). Furthermore,
subclinical psychological problems that do not meet diagnostic criteria for a DSM-IV disorder are
most likely to be “caught” in the medical setting, with an increased chance of prevention or early
intervention. By integrating mental health care into primary care visits, we would be providing
mental health services in the same venue in which they are already being sought. However, services
would be provided in a more responsive, appropriate, and organized manner to improve both the
effectiveness and the efficiency of treatment provided. In addition, providing integrated care in
medical settings also has the potential to reduce the stigma typically associated with specialty
mental health services.
Integrated Care Provides More Service to More People

In addition to the argument that integrated care offers a better match between where clients seek
and receive care, a second rationale for integrated care is the ability to broaden potential client base.
The large epidemiological studies of the past 20 years have taught us that while psychological
disorders are highly prevalent, a great proportion of individuals who endure psychological suffering
do not seek or receive behavioral health care in any forum (e.g., Epidemiologic Catchment Area
Study; Reiger, Myers, & Kramer, 1985). Integrating care would provide a means of accessing popu-
lations who could benefit from behavioral health care but would not otherwise seek treatment.
Thus, by integrating care, we may remove some of the barriers to access for those most in need of
behavioral health services.
The primary care setting has been viewed as the preferred setting for the delivery of behavioral
health-care services because (a) this setting does not carry the stigma that a mental health-care
setting often does; (b) the patient does not have to experience the inconvenience of making
another appointment, resulting in more completed referrals (for example, when a physician refers a
patient to a specialty mental health-care provider in another setting, patients follow through
approximately 15% of the time, whereas when referrals are made to an onsite behavioral health
provider, they are followed through approximately 90% of the time [Strosahl, 1998a]); (c) the behav-
ioral health provider is more skilled at handling disease management issues that stem from treatment
adherence and education problems than the primary care physician; (d) the physician’s time is con-
sidered more costly than that of the behavioral health provider; therefore, assigning behavioral
health issues to the onsite behavioral health provider means more patients can be seen by the physi-
cian; and (e) patients initially receive more services.
Although the argument can be made that initially costs for providing care for those not currently
receiving care would be prohibitive, ultimately, delivering more mental health services may well
lead to a reduction in other forms of expenditure related to un- or undertreated mental illness
(unemployment, judicial costs, medical costs, etc.). Ultimately, then, providing more care to more
people may actually result in reduced costs.
Integrated Care May Improve Treatment of Physical Problems

Not only are people with identified psychological problems more likely to seek treatment in
primary care settings, but the primary care setting is also where physical problems with psychological
correlates or causes are most likely to be treated. By treating psychological problems we may also
improve a patient’s (actual or perceived) physical health.
Of the presenting problems in primary care settings, pain/somatization accounts for 18%, depres-
sion 14%, and anxiety/panic 14% (Fries, Koop, & Beadle, 1993). Furthermore, research indicates
that approximately 90% of the 10 most common presenting problems in primary care settings do
not have an identifiable medical etiology (e.g., Kroenke & Mangelsdorff, 1989). Even for presenting
symptoms that appear to have an organic etiology, such as chest pain, fatigue, dyspnea, and dizzi-
ness, in a high percentage of cases no organic cause is ever identified, suggesting psychological
causes or correlates (Kroenke & Manglesdorff, 1989). Although the insufficiencies of modern medical
technology and diagnostic procedures may account for the lack of positive medical findings in
some cases, the data suggest that a substantial number of medical visits may actually have a “hid-
den” psychological driver (Fries et al., 1993). Furthermore, even when diseases have a known phys-
ical etiology, the management of many chronic diseases requires concurrent behavioral care.
Chronic diseases such as diabetes, chronic airway and respiratory diseases, ischemic heart
disease, pain, and arthritis are highly prevalent, progressive, costly, and, we argue, best treated by an
integrated care approach. The medical care costs alone for people with chronic disease total more
than $400 billion annually. This accounts for better than 60% of all health-care expenditure in the
United States. When indirect costs such as work absenteeism and disability are considered, it is
impossible to calculate the costs of chronic disease.
There is a substantial body of literature showing a high prevalence of psychological co-morbidity
with chronic disease. Specifically, depression, anxiety disorders, and/or substance abuse often
accompany chronic diseases but are all too often undetected and untreated. Chronic disease
patients have been reported to experience high levels of psychological distress (Erdal & Zautra,
1995) compared to controls. The psychological impact of having a chronic medical condition,
however, is not well addressed by conventional treatments (Fore, 1996; Friedman, Sobel, Myers,
Caudill, & Benson, 1995).
Furthermore, chronic diseases frequently require patient self-management and lifestyle modifica-
tion. Behavioral and psychological factors have repeatedly been shown to have a profound impact on
the onset, progression, and management of chronic diseases. For example, patients experiencing mild
depressive symptoms may be less likely to adhere to dietary and exercise recommendations. These
factors in turn are related to treatment costs. In one study, the introduction of an arthritis self-man-
agement group at the Stanford Arthritis Center resulted in not only a 20% reduction in pain, but also
an average 4-year savings of $648 per person in reduced physician visits (Lorig & Holman, 1993).
The importance of treating behavioral problems in the context of chronic medical illness is also
reflected in studies evaluating impact of care on patient satisfaction and outcome. Recent studies
report that patients with chronic illnesses have poor disease control and are generally unhappy with
the care they receive (e.g., Wagner, 1997). In order to improve care for chronic disease patients, sys-
tems of care must be reconfigured. The primary care system was designed to treat individuals expe-
riencing acute problems in the form of a short appointment. This functional triage system relies on
two treatment modalities: prescription medications and brief patient education with an expectation
of patient follow-up. In managing chronic medical illnesses, integrated care emphasizes extensive
patient education about his or her disease, assistance in patient decision making regarding his or
her treatment, managing treatment adherence, treating co-morbid psychological problems such
as depression, and providing change strategies for lifestyle problems such as diet and exercise (see
Figures I.2 and I.3).
Finally, there are sound financial rationales for integrating care. As Cummings, O’Donohue,
Hayes, & Follette (2001, p. 804) remind us, the current writing in integrated care has a certain
“Willie Suttonism” in that the literature strongly suggests that we “go where the money is.” Much
excess spending or “fat” has been carved out of the traditional mental health system. However, it
appears as though more carving will be done in the traditional medical/surgical system owing to
this system’s lack of recognition of behavioral health pathways to medical utilization. One outcome
of integrating care, therefore, is the potential to increase the economic base for the behavioral
health professions through medical cost offset.
Medical Cost Offset

The vision for integrated care is that not only would more people receive more appropriate services,
but that, in doing so, some other, potentially more expensive, services could be avoided or reduced,
resulting in an overall cost savings. This principle is known as medical cost offset (see Cummings,
O’Donohue, Ferguson, 2002, for a review). More precisely, medical cost offset refers to reduced
medical and surgical expenditures attributed to decreased utilization of services when behavioral
health care is provided within that system (Cummings, Johnson, & Cummings, 1997).
$700
$600
$500
$400
$300
$200 Year prior to study
$100 Year after study

$0
Targeted, Other Mental No Mental
Focused Health Health
Therapy Treatment Treatment
Fig. I.2 Chronically ill group. Average medical utilization in constant dollars for the year before (lightly
shaded) and year after (darkly shaded) intervention (from Follette & Cummings, 1967).
$2,000
$1,500
$1,000
$500 Year prior to study
Year after study

$0

Focused Health Health
Therapy Treatment Treatment
Fig. I.3 Nonchronic group. Average medical utilization in constant dollars for the year before (lightly
shaded) and year after (darkly shaded) intervention (from Follette & Cummings, 1967).
The primary route to achieving medical cost offset is adequately treating psychological problems
that may be presented as purely medical problems. It has been shown that patients who have known
psychological disorders use approximately 50% more physical health-care services each year than
patients who are not experiencing psychological distress (Simon, VonKorff, & Barlow, 1995).
Research has demonstrated (e.g., Cummings, Dorken, Pallak, & Henke, 1990) that medical cost off-
set can be achieved through efficient and effective treatment of behavioral problems by reducing
direct medical costs (such as office and emergency department visits). By providing these patients
with more comprehensive and appropriate psychological treatment, the literature suggests that not
only will their psychological symptoms be ameliorated, but they will require and subsequently
utilize fewer physical health resources as well. Cost savings have been estimated to range from
20–40% (Figure I.4; Cummings & Pallak, 1990; Strosahl & Sobel, 1996).
Medical cost offset was initially witnessed in the mid-1960s by Cummings and his colleagues at
Kaiser Permanente in California (e.g., Cummings, Kahn, & Sparkman, 1962; Follette & Cummings,
1967). These researchers found that medical utilization was reduced up to 62% over the 5 years fol-
lowing the application of behavioral interventions, and that the reduction in costs substantially
exceeded the cost of providing the behavioral health service. Additionally, they found that without
any additional behavioral care services, utilization of medicine and surgery, both outpatient and
inpatient, steadily declined to an ultimate level and stayed down, as compared with a comparison
group that did not receive any behavioral health services (see Figure I.4).
Following the release of this finding, researchers began studying the medical cost offset effect,
with varying results. Discussions regarding factors that may influence a study’s ability to detect
medical cost offset (Jones & Vischi, 1980) led Cummings and colleagues to conduct a large-scale,
Average Medical Utilization

120
100
80
Adjusted Dollar
60
40
20
0
1B 1A 2A 3A 4A 5A
Year
Fig. I.4 Average medical utilization for the year before (1B) and the five years after (1A, 2A, 3A, 4A, and 5A)
behavioral intervention was instituted (from Follette & Cummings, 1967).
well-controlled medical cost offset study in the state of Hawaii (Cummings, Doerken, Pallak, &
Henke, 1993; Pallak, Cummings, Doerken, & Henke, 1995). The Hawaii Medicaid Study, as it was
known, was conducted over a period of 7 years with the entire Medicaid population of the Island of
Oahu and in a managed behavioral care setting specifically organized for that purpose under the
auspices of the federal Health Care Financing Administration (HCFA). The study was designed to
address the several scientific criticisms leveled at the medical cost offset research endeavor.
The Hawaii Medicaid Study was prospective in design with all Medicaid eligible persons (N = 36,000)
randomly assigned to experimental and control groups, keeping families intact. The study was
conducted in an organized setting with a staff model. An aggressive outreach program was combined
with programs designed to encourage physician, social work, agency, and community participation.
This controlled prospective study confirmed the results obtained in previous retrospective studies.
The cost of creating the behavioral health-care system was recovered by the medical-surgical savings
within 18 months, and the significant reduction in medical utilization observed initially continued
thereafter with no additional behavioral health care required to maintain the cost savings.
The highest savings were seen in a group consisting of individuals with diabetes, hypertension,
chronic airway and respiratory diseases, ischemic heart disease, and rheumatoid arthritis, who
account for 40% of all Medicaid costs in Hawaii (Cummings, Cummings, & Johnson, 1997). The
control group, which was seen in the fee-for-service private sector for psychotherapy, exhibited a
17% increase in medical-surgical utilization, a finding not statistically different from the 27%
increase in control group patients who did not receive mental health services.
The Hawaii Medicaid Study exemplifies the possibility of observing medical cost offset as a result
of integrated care. Although economic reasons alone may not be considered sufficient rationale for
restructuring routine clinical care, in the context of improved patient satisfaction and functioning,
little additional justification for examining a new model is needed.
Summary of Rationale for Integrated Care

In summary, there are several reasons why serious consideration of integrated systems of care is
warranted. The presence of patients in primary care with clearly stated psychological concerns and
the apparent importance of assessing for psychological contributors to physiological symptoms
suggest a profound mismatch between the primary care environment as it exists and the demand
characteristics of primary care patients. In addition, the traditional model of service delivery does
not appear to be maximizing the available economic resources to provide the highest level of service
to patients for the least cost to payers. Thus, there is currently much interest in integrated care
because it is hypothesized that this type of service delivery will improve patient access, increase the
rate of evidence-based practice, and improve patient health and satisfaction, in addition to reduc-
ing long-term costs.
Implementation of Integrated Models of Care

Although strong rationale can be provided for integrating care, actually conceptualizing how
implementation of such systems could occur requires another level of analysis. There are a number
of factors that must be carefully considered when planning to develop a new integrated system or
shift an existing system to becoming more integrated.
First, adopting an integrated model requires changes in roles for clinicians. For each member of
a multidisciplinary team, being integrated necessitates understanding enough about the disciplines
and training of one’s colleagues to communicate effectively to design collaborative interventions
that will best meet patients’ needs. For most providers, functioning as a team member rather than an
independent operator is a significant shift. Most often, multidisciplinary teams are led by physicians,
not behavioral health providers. For some behavioral providers, this apparent loss in solitary
decision-making power may prove difficult to accept. However, if the longer term goals of integration
(such as providing increased and improved levels of care) meet the values of the clinician, they may
function well as a team member. According to a seasoned integrated care clinician, behavioral
service providers need to conceptualize their role in integrated care as being the medicine, not the
doctor (Friman, 2001).
Strosahl (1998b) has outlined several key points relevant to the role of behavioral health provid-
ers in primary/integrated care settings and identified core assumptions of the model:
1. The behavioral health clinician’s role is to identify, triage, treat, and manage primary care
patients with behavioral health problems.
2. The behavioral health program is grounded in a population-based care philosophy that is
consistent with the mission and goals of the primary care model of health care.
3. All services are based on a primary behavioral health model.
4. The primary care medical team members are key customers (of the behavioral health
clinician).
5. The behavioral health clinician promotes a smooth interface between medicine, psychiatry,
and specialty mental health as well as other behavioral and social services.
There are several specific steps that have been suggested for establishing a new integrated system
of care (or retooling an existing system). First, in order to provide behavioral health services in this
new setting, we must emphasize adequate assessment of probable symptom domains. Given our
training in assessment, this step in the process can often be led by behavioral health providers.
Health screening instruments such as the HEAR or the PRIME-MD (Spitzer, Williams, Kroenke, &
Linzer, 1994) can be utilized for screening for behavioral problems in primary care. Using standard-
ized screening instruments in an integrated setting will be a critical component of conducting a
needs assessment, the goal of which would be to determine which kinds of interventions would be
most useful for the specific clinic population.
Second, based on needs assessment, priority areas should be targeted. Priority areas can be
defined either by high frequency or severity in a given sample. Although targeting particular clinical
presentations based on frequency or severity clearly meets patient demand, this rubric will likely
also target areas that are the most costly. For example, chronic illnesses such as depression, diabetes,
and hypertension are typically managed in primary care and have a high incidence, which would
likely result in these diseases being targeted. In addition, these illnesses often present with and may
be exacerbated by co-morbid behavioral health problems, resulting in lower adherence rates and
more significant (and costly) disability. Ultimately, if poorly managed, chronic illnesses could
require invasive interventions, and result in permanent disability or death.
Although priority areas will certainly differ based on population served, Friedman et al. (1995)
have described specific pathways that might be utilized to produce healthier patients in primary
care. These pathways could be considered a starting point for examining probable priority areas, a
roundup of the “usual suspects,” clinically speaking. These pathways are:
Information and Decision-Support Pathway. Teaching patients the nature and treatment of
their disease, appropriate self-care, and optimal professional utilization increases patient
satisfaction and reduces future medical usage. Psychoeducational groups, bibliotherapy,
individual consultation, and Internet services are means for capturing this pathway.
Stress Management Pathway. Stress is both a key cause of illness and an effect of illness. Pro-
gressive muscle relaxation, meditation, exercise, and other stress management techniques
have been shown to provide positive health benefits in a number of psychological and
medical problems. Stress management, bibliotherapy, and group and individual consulta-
tion are means for capturing this pathway.
Behavior Change Pathway. Changing how a patient, eats, drinks, smokes, uses substances, and
exercises has been shown to have profound implications for health. Lifestyle change
groups, bibliotherapy, smoking cessation psychotherapy, and substance abuse treatment
are ways of capturing this pathway.
Social Support Pathway. Some patients enter the health-care system to obtain social support.
Even patients who have high levels of social support under ordinary circumstances may
develop feelings of isolation when experiencing chronic illness. Increasing social support
through peer-led groups and activation of natural support networks have been shown to
improve health and reduce future medical utilization.
Undiagnosed Psychological Problem Pathway. In many cases patients present with medical
complaints but actually have an undiagnosed psychological problem such as depression
and anxiety. Training in the accurate diagnosis of these as well as the use of less expensive
but highly effective psychological treatments result in significantly less medial utilization.
Managing successful referrals to specialty care is also part of the service.
Somatization Pathway. Some patients who very frequently present with multiple somatic
complains may have increased emotional reactivity to bodily changes. These individuals
tend to be high utilizers of medical services. Psychological consultation involving relaxation
training, cognitive restructuring, and psychoeducation have reduced medical costs signifi-
cantly in patients with somatizing patients.
Once particular problem areas have been chosen and targeted, the next task in establishing an
integrated model is to apply evidence-based interventions. It is critical to the functioning of
an integrated system that protocols are in place to guide the practice of the multidisciplinary team.
As described above, protocols should be in place for (at minimum) high base-rate psychological
problems, co-morbid psychological/medical problems, and patterns of behavior that could exacer-
bate the disease process (e.g., not following medical directions). Disease management protocols
have been developed for a variety of medical and behavioral conditions and some have been shown
to be effective. Strosahl (1998b) and Cummings (1996a) propose that the lack of effectiveness of
some (medically focused) disease management programs has been due to their relative insensitivity
to common behavioral health co-morbidities such as depression, anxiety, and substance abuse.
Likewise, few psychological treatment protocols have been empirically tested in primary care
environments. These limitations of the current literatures may prove to be a significant barrier in
choosing protocols to implement. Mindful of this fact, if available, system administrators should
plan to implement practice guidelines that have been derived from the empirical literature and,
when such guidelines are not available, be prepared to follow current best practices and collect data
with an eye toward developing empirically supported practice guidelines.
Finally, once protocols have been implemented, ongoing quality management is essential for the
maintenance and further development of an integrated practice. To do so first requires systems
administrators to define the outcome variables of interest. Of course, outcomes related to disease
processes (e.g., improved physical or behavioral functioning) should be measured, but integration
also invites the examination of a novel set of outcome variables. For example, variables such as
medical utilization, direct and indirect costs of providing care, adherence to prescribed treatment
regimens, and patient and provider satisfaction may be additional variables of interest. Ultimately,
ongoing data collection will provide a means of evaluating existing programs and making necessary
changes to improve effectiveness and efficiency of products.
What Is the Evidence for Integrated Care?

Integrated care appears to be very much “at the edge” of science and practice. As a result, there has not
yet been a proliferation of published research in the area. However, the available data are promising.
Studies have shown that integrating behavioral health services into primary care can (a) improve
patient satisfaction (e.g., Katon, 1995); (b) improve provider satisfaction (Katon, 1995); (c) improve
patient outcome (Cummings, 1997; O’Donohue et al., 2002); and (d) decrease health-care costs
(Chiles, Lambert, & Hatch, 1999). Strosahl (1998b), Cummings (1997), and other experts in integrated
health-care delivery suggest that the common elements of successful integrated programs are: (a) full
integration of mental health providers and services within the primary care clinic; this typically
involves colocating the behavioral health provider in the primary care setting; (b) structured treatment
programs; (c) emphasis on follow-up care; and (d) sensitivity to the ecology of primary care.
Putting Theory Into Practice: The Purpose of This Book

The theoretical underpinnings of integrating behavioral and primary care practice have been thor-
oughly discussed in previous books (Cummings, O’Donohue, & Ferguson, 2002; Cummings,
Johnson, & Cummings, 1997). However, to our knowledge, no texts to date have provided guide-
lines on how to practice integrated care. That is the intention of this book. We have structured this
book to provide specific examples of behavioral problems targeted in integrated care and guidelines
for behavioral health providers in treating these problems, including conducting assessments and
performing triage functions. This book is intended to extend and bridge the existing literatures of
integrated care, behavioral medicine, consultation-liaison psychiatry, medical cost offset, and
health-care economics.
To this end, the contributing authors were required to provide a detailed definition of the problem
area their chapter addresses, recommendations for assessment, a proposed protocol for the treat-
ment of said problem within a medical context based on relevant research findings (when available),
a discussion of medical cost offset (either observed or hypothesized), and suggestions for future
research directions. Chapter topics were chosen based on two factors: prevalence of the problem
and the extent to which integrated models of care have been established for the problem.
We have chosen three main content areas for this text. First, the treatment of psychological prob-
lems in the context of primary medical care will be addressed in several chapters (3–9). In these
chapters, the psychological problem is considered to be the primary treatment target, and, indeed,
the probable raison d’etre of the primary care visit. In addition, several chapters (10–17, 19) address
co-morbid psychological factors that play key roles in the effective management of physical diseases,
either acute or chronic. Finally, several chapters (1–3, 18) address issues relevant to the overall prac-
tice of integrated care.
In summary, the aim of this book is to provide a comprehensive and current handbook of clinical
protocols that may be applied in integrated care. We hope that this book will facilitate both
expanded and enriched practice. In addition, we hope that these chapters will educate readers to the
existing empirical literature on integrated care, which has previously existed primarily within
specialty medical journals. In doing so, we hope to inspire clinicians and researchers to engage in
and contribute to the burgeoning practice and study of integrated care with the ultimate goal of
improving patient health and well-being.
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Chapter 1
Training Behavioral Health and Primary Care
Providers for Integrated Care: A Core
Competencies Approach
KIRK D. STROSAHL
Managed behavioral health care has had a profound effect upon the delivery of behavioral health
services in the United States. What was once a “cottage industry” has been transformed into a
mature industry that is subject to increasing scrutiny by accrediting bodies, purchasers, and
consumers. The ferocity of the managed behavioral health-care movement itself is based on
recognition that the behavioral health industry is a “player” in the American health-care
scene. Although proponents and opponents of managed care can argue the merits and drawbacks
of this socioeconomic movement, one truth is clear: behavioral health care in the United States
has been and will continue to be transformed by the same influences that have transformed general
health care.
Despite the success associated with this rise to prominence, it is useful to remember that
behavioral health care is embedded within a larger system of general health care. Of the approxi-
mately $1.6 trillion spent annually on health care, less than 10% is allocated to behavioral care
(Coffey et al., 2000; Strosahl, 1994). Although the United States spends more of its gross national
product on health care than any other country in the civilized world, the health “report card”
for America does not look good when compared with countries that spend far less on their systems
of health care. A recent Institute of Medicine (Richardson, 2001) report concluded that the
American health-care system (including behavioral health care) is broken, characterized by a pro-
found mismangement of available resources, which frequently results in decreased quality of care.
Although inordinate financial resources are being poured into the American health care every day,
the final product leaves much to be desired. In the past 2 years, health-care premiums have once
again begun an upward trend. This is disconcerting because most health-care financing experts
agree that the floor of cost-cutting strategies has been reached. Many health plans are refusing to
participate in insurance programs that cannot generate reasonable operating profits (i.e., state
Medicaid programs), indicating a growing willing-ness to sacrifice economy of scale for greater
profitability. One must conclude that the Draconian cost-cutting strategies of Generation One of
managed care have failed to cure very basic flaws in the way health care is delivered in this country
15
(Strosahl, 1995). What will be required to correct this sad state of affairs is a reengineering of the
basic process of health care, not simply the modification of long-standing practices.
Integration of Services: A Major Driver of Health-Care Redesign

The integration of primary care and behavioral health services is an integral part of health-care
redesign (Dobmeyer, Rowan, Etherage, & Wilson, 2003; Pruitt, Klapow, Epping-Jordan, &
Dresselhaus, 1998; Strosahl, 1995, 1996, 1997, 2001). The explosion of interest in primary care
behavioral health integration is demonstrated by the appearance of authoritative texts on the
subject, pre- and postdoctoral fellowships devoted to working in primary care, and Websites, as
well as the appearance of crossover training programs for family physicians and psychologists.
Large systems of care in both the public (e.g., Bureau of Primary Health Care, U.S. Air Force, U.S.
Navy, Veterans Administration) and private sectors (e.g., Kaiser Permanente Northern California)
have launched full-scale, primary care behavioral health integration initiatives. Although it is
tempting to create a simplistic picture of the factors driving service integration, there are three
major drivers of the integration movement: health-care utilization patterns, consumer preferences,
and the economics of health-care reform.
We Built It and They Didn’t Come: Failure of the Segregated Model of Mental Health Care
For more than two decades, it has been widely accepted among health-care researchers that primary
care is the “defacto behavioral health system” in the United States. There is compelling health ser-
vices and epidemiological evidence indicating that the vast majority of behavioral health services
are delivered solely by general medical providers (Narrow, Reiger, Rae, Manderscheid, & Locke,
1993; Regier et al., 1993; VonKorff & Simon, 1996). There is incontrovertible evidence pointing to a
strong relationship between psychological distress, increased medical service utilization, and poor
health outcomes (VonKorff & Simon, 1996; Wells et al., 1989). Indeed, many studies have demon-
strated that the majority of primary care visits are driven by psychosocial factors (Kroenke & Man-
gelsdorff, 1989). At the same time, primary care providers point out that the work pace of primary
care medicine, as well as physicians’ lack of behavioral health intervention skills, makes it difficult if
not impossible to address the behavioral health needs of their patients. Sobel (1995) has suggested
that the tremendous demand for psychosocial services, combined with the improper configuration
of the health-care system, results in a chronic mismatch between what most primary care patients
are seeking (i.e., psychosocial interventions) and what most are receiving (general medical services,
tests, and procedures). This mismatch generates a “revolving door” problem in primary care that
leaves providers demoralized and patients dissatisfied.
With this information in hand for so long, why have health-care systems not been interested in
integration earlier? Frankly, the economic incentives in the premanaged care era favored waste and
fragmentation. The more wasteful health systems were, the richer they became! Managed care
reversed the rules of the game by shifting financial risk to the provider of service through such
strategies as case rates, capitation, and various types of utilization management. Now, health-care
systems are discovering that it is difficult to manage both the service burden and financial risk when
a chronic and pervasive need such as behavioral health is simply ignored.
Ironically, behavioral health carve-outs, with their much-heralded success at cutting behavioral
health costs and improving access to services for selected segments of the population, have created a
significant impetus for integration. In essence, carve-outs have not only formalized the segregation
of health and behavioral health services, but have effectively shifted the service and financial burden
for behavioral care to the health-care system (see Strosahl & Quirk, 1994). The inadequacy of most
health-care insurance databases has allowed this population shift to go largely undetected. Further,
Training Behavioral Health and Primary Care Providers for Integrated Care • 17
carving out behavioral health care has resulted in poor communication, lack of care coordination,
and a basic confusion of roles between health-care and behavioral health-care providers. Whether
knowingly or unknowingly, the progenitors of carve-outs have steadfastly ignored the overwhelm-
ing population data that point to the need to deliver behavioral health services in primary medical
settings. Instead, most carve-outs refuse to pay for such services or, if payment is made, it is at a
steeply discounted rate. This means that, contrary to the claims of carve-out executives, behavioral
health care is inaccessible to the vast majority of Americans who will not agree to receive their
behavioral health in the settings and from the providers dictated by the carve-out companies. In
essence, the first generation of managed behavioral health care has resulted in an expensive system
of care that most consumers will never use.
Consumer-Centered Care
A second major factor in the drive toward integration is the increased role of consumer preference
in determining not only how services will be delivered, but where they will be delivered. For
decades, a “provider-centered” model of service has characterized American health care. Generally,
this means that the provider community determines when, where, and how services are to be
delivered. The consumer’s role has been to comply with these systemic rules. Managed care has
inadvertently contributed to the rise of “consumer-centered” care. In their marketing efforts to
enroll and retain new consumers, health-care systems began the dangerous process of asking con-
sumers what they wanted in their health care. One clear theme that has emerged is that consumers
want a less fragmented system of care that emphasizes “one-stop shopping.” Most consumers would
prefer to receive behavioral health services in the same location and in the same time frame as they
receive health-care services. It is extremely inconvenient to have to attend several appointments on
several different days in several different facilities, when the same services could just as easily be
delivered during a single health-care visit. Consumers generally would like access not to just behav-
ioral health services, but oral health, physical therapy, and other adjunctive health services. It is fair
to say that the voice of the consumer will be a major determinant of how the American health-care
system of the future is designed.
Economic Drivers of Integration

The economic forces pushing the integration of behavioral health are closely tied to service population
characteristics. A service need that exists in 70% of the medical population is a serious economic
issue. Systems analysts and health-care administrators are well aware that recycling patients because
their behavioral health needs are not adequately addressed converts directly into uncontrollable
medical costs. Essentially, patients never leave the health-care system; so when service needs are not
addressed, the patient’s general health status deteriorates, leading to a greater medical services
burden in the future. Further, the burden of managed care is “to do more with less.” Up until
recently, health-care premiums were rising at about the rate of general inflation, while insurance
coverage increased to include more services. Expanding services without adding significant revenue
means that the productivity of health-care providers is a central concern to system administrators.
Inefficient delivery systems that drain away the capacity of medical providers will simply not be able
to compete in the health-care marketplace of the next decade. At the same time, as productivity
standards have increased (i.e., some general physicians now are responsible for as many as 3,500
patients), the feedback from medical providers is that their productivity is severely hampered by the
ongoing problem of having to address behavioral health needs during medical exams. Furthermore,
the ongoing mismatch between what the patient seeks and what the provider is prepared to deliver
demoralizes medical providers, increases the risk of provider burnout, and creates difficulties in
recruiting and retaining medical providers. Finally, the financial burden of maintaining highly
segregated systems with many core administrative redundancies results in an unacceptably high
percentage of the U.S. medical dollar’s failing to reach the field. The segregation of health and
behavioral health is so complete that separate administrative and governmental infrastructures
exist from the level of federal government all the way down to the community. It is impossible to
calculate how much of the health-care dollar is drained away by the bureaucratic maze of health
care. It suffices to say that no other country devotes so much money to such an unproductive and
unnecessary administrative infrastructure.
This rather long background on the integration movement is necessary because it creates a
context for understanding the basic nature of health-care redesign. Integrating behavioral health
services into primary care systems is not simply a matter of taking the traditional mental health
specialty model and dropping it in a primary care center. The volume of behavioral health needs in
the primary care population will far outstrip the capacity of the traditional specialty model of
behavioral health care. Primary care centers and practice groups are searching for far more basic
answers to the problems that confront their medical providers on an hourly basis. This will require
building behavioral health service delivery models that are modeled after primary care medicine
in mission, goals, and strategies (Dobmeyer et al., 2003; Strosahl, 1996, 1997, 1998, 2001). There is
no precedent for this in the United States and most training programs for behavioral health- and
primary care providers remain steadfastly rooted in mind-body dualism and a segregated system of
care. However, we can capitalize on the experience of other countries such as the United Kingdom,
where there is a long history of both service integration and clinical research (Goldberg, 1990).
Analysis of these systems of care suggest that, in order to successfully integrate behavioral health-
and primary care services, medical and behavioral health providers will have to learn new strategies
for working together. This book addresses one very basic issue in this quest: how to build clinically
effective and cost-efficient intervention protocols for high-volume, high-impact conditions seen in
primary medicine. This chapter examines one of the most basic and perplexing aspects of the trans-
formation to integrative primary care: how to “retrain” behavioral health- and primary care pro-
viders to work together effectively to respond to the overwhelming behavioral health needs of
primary care patients. To provide some answers to this multifaceted question, it will first be of value
to examine the characteristics of the primary care milieu, to understand characteristics of the most
effective models of integration, and to appreciate the demands these new models of care will make
of primary care and behavioral health providers. This will allow for a better appreciation of the
substantial training issues involved in this type of system redesign. The final sections of this chapter
will introduce a skill-based, core-competency training model that has been successfully imple-
mented in both small- and large-scale primary care behavioral health integration initiatives. I will
identify and discuss the core competencies required of primary care and behavioral health provid-
ers when working in a primary care team model. Finally, I will describe the sequence of training
strategies that have produced the most successful training outcomes.
The Gestalt of Primary Care: Implications for Training

The primary care milieu is vastly different from the mental health clinic/office practice setting.
These differences have profound implications, not only for the types of services that will be
provided, but also for the goals and methods of training programs for primary care and behavioral
health providers. The most basic difference lies in the contrasting missions of primary care and
mental health systems of care. Grounded in the basic concepts of public health and epidemiology,
primary care systems seek to raise the health of the entire population, not just a portion of it.
The guiding mission of primary care is “population based care” (Eddy, 1996). The goals of
population-based care are to (a) prevent the onset of illness through the management of health risk
factors, (b) engage in early detection and management of illnesses, (c) provide stepped care for
health-care problems in an attempt to manage most conditions within primary care, (d) provide
palliative and chronic medical management for patients with chronic or progressive diseases, and
(e) manage the total health-care needs of patients through referral to and coordination with medi-
cal subspecialists and adjunctive services such as behavioral health. In general, a primary care sys-
tem must be prepared to address the full spectrum of health-care concerns that are likely to exist in
the community being served.
In contrast, the concepts of population care are largely absent in the design of behavioral health
systems of care, and few behavioral health providers understand even the most basic principles of
this model. Most mental health training programs do not provide any education in such basic
content as health-care economics, evidence-based care, and population health. Few postgraduate
programs in any discipline other than psychiatry provide practicums in primary care centers, so
that graduate students can get a “feel” for the primary care milieu. Consequently, entering the
primary care setting can be daunting to the behavioral health provider. First, the work pace in
primary care is much faster than that in a behavioral health setting. Primary care providers will
average 24–34 patients per day, seen in 10–15 minute medical appointments. Often, three or four
patients will be processed simultaneously, in a highly choreographed service-delivery model involv-
ing nurses, midlevel providers, and the general physician. The goals of population-based care can
be achieved only by constructing a delivery system that has the capacity to provide basic medical
services to a very large portion of a community population. Typically, a primary care system will
provide at least one ambulatory medical service to 80% of the members of a community on an
annual basis. In contrast, the typical behavioral health system will provide services to only 3–7% of
the population, depending upon the service setting (Strosahl, 1996, 1997). This relatively low pene-
tration rate allows behavioral health providers to be trained to provide longer episodes of care in
the fabled 50-minute hour model.
Second, primary care patients tend to be more ethnically diverse and older, and have a much
higher proportion of males than is true for the mental health populations. In addition, primary
care patients present with a bewildering diversity of psychosocial issues. As has been highlighted
in other writings (Strosahl, 2001), most of the major psychosocial drivers of health-care seeking
are not related to mental health or chemical dependency factors, as classically defined. For example,
a patient with a new diagnosis of diabetes might fail to follow behavior-change guidelines
for diabetic self-management. Another patient might present for care repeatedly owing to migraine
headaches that can be triggered by stress, smells, physical exercise, and so forth. These types
of problems are commonplace in primary care, but they are not traditional mental health or
substance abuse problems. They are, however, deeply rooted in patients’ ability to change habits
and behaviors.
As might be expected, the interaction of these health and psychosocial factors is a basic feature of
working in primary care. Primary care patients are much more likely to have health issues that both
impact and are impacted by behavioral health factors. Such patients frequently require a combina-
tion of interventions that are rarely used in mental health settings. At the same time, the volume of
patients streaming through primary care generally requires less intense episodes of care and a much
greater reliance on management of the patient by the health-care team over time.
Finally, one of the major transformations occurring in health care is the growing influence of the
health-care team (HCT) model. This approach molds the traditional solo physician practice into a
team-based enterprise, so that the doctor-patient relationship is changed into a team-patient
relationship (Taplin, Galvin, Payne, Coole, & Wagner, 1998). Members of the typical health-care
team include the medical assistant, nurse, physician assistant, advanced nurse practitioner, and
general physician. The behavioral health provider in primary care will operate within a team milieu
that is constructed very differently from that encountered in traditional behavioral health settings.
Training Implications. Adapting the mission, goals, and strategies of mental health to fit the primary
care environment will require both a modification of the mental health service delivery model and
the acquisition of new skills by behavioral health providers and their primary care colleagues
(Robinson, Wischman, & Del Vento, 1996; Strosahl, 1996, 1997, 1998, 2001). At the level of post-
graduate training, mental health providers need much greater exposure to concepts of population
care, health-care economics, and evidence-based care. All of these are central and defining features
of contemporary general medicine. In addition, students need to learn about aspects of the primary
care population that will require a different “lens” to be used in both conceptualizing cases and
delivering appropriate interventions. Providers will need to be trained to identify medical condi-
tions that produce symptoms that mimic mental disorders and become conversant in psychophar-
macology, behavioral medicine, and health psychology. If these skills are not acquired in graduate
training, they will need to be learned as part of the “on the job” retraining process.
Models of Primary Care Integration: Implications for Training

The first principle in developing effective integration training programs is that the model of
integration drives the content that must be mastered and the skills that will have to be acquired. It is
important to understand that a range of primary care behavioral health integration models have
been used with varying degrees of success (see Dobmeyer et al., 2003, and Gatchel and Oordt, 2003,
for reviews of these approaches). Most health-care administrators have limited knowledge
of behavioral health services in general and might not appreciate the training needs associated
with different approaches to service integration. Therefore, it is important that behavioral health
providers understand the central characteristics of the most common integration models. These
models vary considerably in their underlying philosophies and associated clinical goals, strategies,
and practice structure.
The Primary Behavioral Health Model

The primary behavioral health model is a framework for developing and delivering behavioral
health services in a manner that is consistent with the mission, goals, and strategies of primary care
(Strosahl, 1996, 1997, 1998, 2001). Briefly, this consultation-based approach emphasizes providing
basic behavioral health services to a wide variety of patients seen by members of the primary care
team. The behavioral health consultant functions as an integral part of the health-care team and
attempts to improve the quality of psychosocial interventions delivered by any team member.
To achieve this objective, the behavioral health provider consults with health-care providers and
may engage in temporary comanagement of certain patients.
There are two distinct but complementary dimensions within the primary behavioral health
model: general consultation services and chronic condition programs. It will be useful to describe
the two components in more detail.
General Consultation Services. General consultation services are the behavioral health equivalent
of a general primary care practice. The goal is to see any referred patient regardless of the type of
problem or level of need. Drawing from the classic Peanuts cartoon series, this approach is often
called the “Lucy is in” model. In the cartoon, Lucy is seen sitting in a Kool-Aid stand with a sign
saying, “See the Psychiatrist for 5 Cents.” Similar to Lucy, the behavioral health consultant offers
such easy access to general consultation services by “setting up shop” in the exam room area.
The approach is to “see all comers” regardless of the type of behavioral health issue that is involved.
When working in a general consultation service, it is not at all unusual for the behavioral health
consultant to see 14–18 patients in a practice day. Consultation sessions tend to be very brief and
focused on helping the doctor and patient successfully address a specific problem.
Chronic Condition Programs. These programs are also referred to as critical pathways, clinical
roadmaps, disease management, or chronic-condition management programs. There is a growing
emphasis in general health care on developing evidence-based clinical practice protocols for
common disease conditions such as diabetes, asthma, and cardiovascular disease (Geyman, 1998).
Similarly, chronic condition programs focus on a specific condition that is commonly seen in gen-
eral medical practice. The goal of such programs is to create standard treatment guidelines, care
protocols, and processes that produce the best clinical outcomes for the most patients. In chapter 2,
Robinson describes various parameters for selecting behavioral health conditions that are good
candidates for such programs. Generally, the condition needs to be well represented in the primary
care population (i.e., depression, panic disorder) and/or have significant impact on service utiliza-
tion and cost (i.e., chronic low-back pain). Second, there is one or more behavioral or psychophar-
macological treatment that is known to be effective. Finally, an analysis of the cost savings and/or
improvements in clinical outcomes justifies the institutional costs involved in developing the path-
way (Geyman, 1998).
In chapter 2, Robinson also describes various principles for adapting evidence-based behavioral
health treatments to the primary care setting. She concludes that we cannot just transfer evidence-
based behavioral health treatments into primary care, any more than we can simply transfer the
specialty mental health model into primary care. Evidence-based treatments must be adapted to fit
the primary care milieu and address the unique preferences of primary care patients. This will
require the developers of such protocols to be highly attentive to the factors that will make these
models of care acceptable to both patients and providers (Robinson, 1998; Robinson & Strosahl,
2000). However these protocols are developed, they must still be delivered by a team comprising
medical and behavioral health providers in the context of daily practice.
Training Implications. Behavioral health providers working in the primary behavioral health
model need to be comfortable with very fast-paced sessions and need to possess a variety of
assessment and intervention skills in the areas of mental health, chemical dependency, behavioral
medicine, and health psychology. They need to be very effective communicators and have the
ability to consult with medical team members. The skills needed to deliver chronic condition proto-
cols overlap with, but are distinct from, the skills required of the general consultant. The provider
must still adopt a brisk work pace, conduct brief and structured sessions, and continue to see many
patients in a practice day. In addition, the behavioral health consultant must understand the clinical
evidence for treatment of a certain condition and be able to convert this knowledge into a psychoe-
ducational format that emphasizes skill building and home-based practice. The consltant must also
understand how to assess, monitor, and quantify clinical response during each visit.
Colocated Specialty Model

An alternative integration model is the colocated specialty approach. This involves locating a
behavioral health provider within the primary care clinic with the goal of providing traditional
mental health and chemical dependency services to patients referred by general medical providers.
The behavioral health provider is responsible for providing specialty treatment while attempting
to coordinate care with referring medical providers. A full range of traditional mental health
services is available, including individual, couples, or family therapy. A traditional service delivery
model is employed that includes 1-hour therapy sessions and/or longer group therapy sessions.
The services may even be delivered in an evidence-based care framework using treatment manuals
or other protocols.
The “family systems health-care” model is a variant of the colocated specialty care approach
(Doherty, McDaniel, & Baird, 1996; McDaniel, Campbell, & Seaburn, 1990). In this approach,
the behavioral health and primary care providers conduct regular staff reviews of shared patients
and may even conduct conjoint therapy sessions. This model is designed to increase collaboration
between medical and behavioral health providers and support the delivery of specialty behavioral
health care. Although the behavioral provider is physically colocated, he or she does not function as
a core member of the primary care treatment team, but rather is viewed as an in-house specialist
that is available to take same-day referrals. In this model of care, the patient flow is significantly
smaller than in the consultation approach and the work pace of the behavioral provider more
closely resembles that seen in a mental health clinic.
The chief drawbacks of this approach are indigenous to the specialty model of care. First,
specialty care by design is labor intensive and lacks the capacity to serve a meaningful percentage of
the primary care population. There is a tendency for colocated specialists to be bombarded with the
most difficult patients early on (many require the most intensive forms of clinical management),
and it can develop the same access problems that have plagued mental health specialty settings. For
all intents and purposes, this is not a “population health” model because it does not seek to provide
services to a large segment of the primary care population.
A second, subtle drawback is that the specialist approach, even in the collaborative health-care
model, reinforces the idea that health care and behavioral health care are separate processes. When
primary care providers send patients with behavioral health problems out of the medical exam
room area, they are communicating that behavioral health is not a core aspect of quality health
care. Finally, the colocated specialty approach is unlikely to have a great impact on the way primary
care providers intervene with commonly seen behavioral health problems. If a specialist is needed
to handle behavioral health problems, then primary care providers will continue to believe that
they cannot be expected to deal with them during medical exams.
Although proponents of the collaborative family health-care approach contend that physicians
learn basic mental health skills by conducting conjoint therapy sessions and attending weekly case
conferences, years of experience in applied primary care settings suggest that most physicians do
not have the time or interest to participate in conjoint sessions or behavioral health case
conferences. Nevertheless, my experience is that primary care providers generally have positive
evaluations of colocated specialty services. After years of finding such specialty services virtually
unavailable for their patients, primary care providers will see the addition of an onsite specialist as a
definite step forward. At the same time, medical providers will readily admit that this model does
not really promote the behavioral health of the population served to any meaningful extent, nor
have they learned much about how to intervene with behavioral health issues in the exam room.
When health-care systems are given the choice between adopting a colocated specialist approach or
the primary behavioral health model, they choose the latter almost without exception. This is
because the primary behavioral health model is really a basic form of primary care.
Training Implications. The chief benefit of the colocated specialist approach is that it requires the
least adaptation of existing skills by behavioral health- and primary care providers. The model is
familiar to both medical and mental health providers and does not strain any existing paradigms.
Most reasonably trained behavioral health providers can deliver an array of specialty services and
can adapt to the primary care milieu. Further, primary care providers can easily be taught to detect
and refer patients who could benefit from specialty behavioral health services. I believe that the
vigor with which the colocated specialist model is being supported by the mental health industry is
largely due to the fact that it requires little change in training programs or the practice patterns of
providers in the field.
An Integrated Training Approach for Behavioral Health and Primary Care Providers
Practice in integrated care settings can range from slightly modified versions of the specialist
approach to models of care that are much more like primary care services. The general rule is the
more traditional and “mental health–like” the integration program is, the less retraining is needed.
As noted, however, the more traditional colocated specialist models lack the population health
focus and capacity to have a significant impact on the primary care population. Consequently,
I generally recommend that primary care clinics and systems adopt the primary behavioral health
approach and, in the overwhelming majority of situations, system leaders agree with this assess-
ment. When this bridge is crossed, implementing an effective in-the-field training program for
both behavioral health and primary care providers emerges as a central issue. The rest of this chapter
will be devoted to describing an integrated training model designed to help primary care and
behavioral health providers succeed in this primary care team-based approach. The training pro-
gram is “integrated” in two senses: (1) It nearly always involves providing didactic training to both
medical and behavioral health providers; and (2) the model incorporates multiple training methods
ranging from didactic workshops to “shadowing” medical and behavioral health providers in prac-
tice. All of the training methods have the same central goal: to improve the providers’ intellectual
understanding of this model and its underlying philosophies, as well as to build concrete practice
skills that will make the provider as effective as possible. Table 1.1 presents some of the training
methods that are employed, as well as some of the hoped-for training outcomes.
Generally, the training sequence starts with didactic workshops that introduce participants to
the primary behavior health model in general. When behavioral health and medical providers are
introduced to this model of integration, their reactions are somewhat different. Medical providers
have trouble believing they can deliver effective behavioral health interventions in the 2- to
3-minute time frame of a routine exam, and they are unclear about how the team-based behaviorist
can assist them in the exam process. Mental health providers are generally skeptical about the
feasibility of 15- and 30-minute sessions, and they find it hard to imagine how they could “handle”
12–16 patients in a practice session. In my experience, most of these reactions originate from an
“attachment” to a specific mental model of human psychopathology, how behavior change occurs,
and the role the intervener plays in producing change. As the didactic training proceeds, I begin to
examine these issues in more detail, primarily to reveal the widespread controversies that exist in
each of these fundamental paradigmatic arenas. My goal is to reveal beginning assumptions for
what they are: just assumptions. The most dangerous thing about beginning assumptions is that,
although they seldom can be scientifically proven, they take on the aura of being eternal “truths.”
Understanding Basic Issues in Behavior Change

To a very significant extent, the way we conceptualize human suffering and psychopathology, how
behavior change occurs, and the role of the intervener in producing behavior change defines the
magnitude and feasibility of the job at hand. Whereas medical providers get trapped in their
assumptions without knowing it, because of the general inadequacy of their mental health training,
behavioral health providers are wedded to their assumptions from graduate school onward. These
assumptions are near and dear to behavior health providers, and letting go of them in the face of
conflicting evidence is very difficult. Most graduate training programs have a specific theoretical
TABLE 1.1 Educational Methods and Learning Goals for an Integrated Primary Behavioral Health-Care
Training Program
Training Method Learning Goals
Didactic training Understand prevalence and impact of behavioral factors
Understand major psychosocial drivers of health-care seeking
Appreciate basic concepts of population health care
Understand model of care and continuum of integration
Appreciate concepts supporting effective assessment, brief and strategic
interventions
Understand how to adapt and apply evidence-based treatments in primary
care practice
Clinical case vignettes and Learn to apply basic concepts of functional and diagnostic assessment
best-practices video training Apply brief and strategic intervention concepts in practice
sessions Understand how to monitor progress and track at-risk patients
Appreciate how to structure ultrabrief clinical encounters
Clinical and administrative Appreciate philosophy and service parameters of integrated care program
services manual Understand administrative requirements, policies, and procedures
underpinning program
In vivo job shadowing, Promote increased awareness of primary care practice styles
academic detailing, Develop core practice competencies
supervised clinical practice Improve effectiveness in adapting evidence-based treatments to primary care
using core competencies milieu
framework Adapt to the gestalt of primary care and the team-based treatment setting
Mentoring and extended Create framework for developing core competencies over time
practice consultation Provide forum for identifying and solving practice issues over time
doctrine (i.e., cognitive behavioral, humanistic, psychodynamic) that explains how human suffering
originates, what is required to “fix” it, and what the role of the therapist is in that process. Moreover,
there are other hidden conventions that nearly all programs adhere to, regardless of the theoretical
model (i.e., the 50-minute hour). These beginning assumptions carry an air of sanctity that drives
the a priori rejection of innovative ideas about behavior change. For example, many behavioral
health clinicians will chafe at the idea of brief 15-to-30-minute encounters. They will emphatically
claim that such brief encounters lead to clinical errors and only superficial treatment effects.
Observing this rigidity in their behavioral health colleagues, primary care providers claim that
anything short of a specialty approach to assessment and intervention is ineffective. Since primary
care exams do not allow for such comprehensive assessments and interventions, a primary care
provider cannot deliver effective interventions. Thus, patients requiring mental health care should
be referred out of primary care. This is one of the chief benefits of conducting didactic training
with an intermixed group of medical and behavioral health providers. It allows providers on each
side of the fence to witness the conceptual struggle of their colleagues while at the same time notic-
ing that the struggle takes on different forms based on one’s training background. Therefore, the
struggle has to be related to what has already been learned and how new perspectives and informa-
tion can be integrated into the previously existing “mental map.”
Medical Illness Versus Stress-Coping Models of Human Psychopathology

The first and most salient issue involves the assumptions implicit in various models of psychopa-
thology and human suffering. For a variety of political and economic reasons, the medical model of
psychiatric illness has been and will continue to be the mainstay of the medical community, including
primary care. The medical model holds that behavioral health conditions are disease entities that
can be described in terms of DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th
edition) categories. Once the correct diagnosis is made, a specific treatment is indicated. A major
informal assumption of this approach is that psychological well-being is the natural resting state of
human beings, much as health is the natural physical state. Similar to diseases on the medical side,
behavior disorders are a deviation from that state of healthy equilibrium. This leads to terms such
as illness or disease being used to describe various psychiatric syndromes. In other writings (Hayes,
Strosahl, & Wilson, 1999; Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), this assumption has
been shown to be not only logically flawed, but to a great extent inconsistent with the empirical lit-
erature on the causes of psychopathology and behavioral dysfunction. The strongest predictors of
human behavioral dysfunction are not biological or genetic factors, but rather basic coping styles
(i.e., problem-focused versus emotion-focused coping, experiential escape, and avoidance). Even in
contemporary medicine, health is conceptualized not only as the relationship between pathogenic
and disease-buffering processes, but also as a state of mind and a sense of well-being. This means
that a patient with a chronic disease such as diabetes can be “healthy” if he or she is managing his or
her blood sugar; pursuing work, intimacy, family, or spiritual goals; and experiencing a sense of
psychological well-being. Unfortunately, this more advanced conception of health has not been
transferred to the psychiatric taxonomy, and it is still common to hear medical and behavioral
health providers describe mental health and substance use syndromes as biologically driven disease
states that require specialized treatment. By default, most primary care clinicians are exposed only
to the medical model of human psychopathology in their graduate training. One physician com-
mented to me that his formal mental health training in residency was to memorize the DSM-IV!
The concepts of syndrome and illness are familiar to most medical providers, and it drives much
of their overreliance on medicines as the first-line treatment response for almost any psychologi-
cal complaint.
The vast majority of behavioral health clinicians in the United States are not medically trained
and, in general, do not share the same allegiance to the medical model as their medically trained
colleagues. Most forms of brief and strategic therapy have originated in the nonmedical wing of the
behavioral health industry, and most assume that psychopathology is the by-product of increased
life stress or ineffective coping responses. Indeed, a strong case can be made that most empirically-
validated cognitive behavioral treatments are rooted in a stress-coping framework. Many of the core
interventions in these treatment packages build coping and stress-reduction skills.
In general, stress-coping models hold that humans exist in a dynamic environment that involves
responding to internal and external stresses with stress-buffering or coping responses. Generally,
human psychopathology involves the interplay of three major social and psychological compo-
nents: recently occurring stresses that can vary in magnitude from daily hassles to major life events,
personal dispositions that determine the “reactivity” of the person to stresses (traits, genetic vulner-
abilities, resources, and liabilities derived from remote learning histories), and the patient’s reper-
toire of coping responses (stress reduction skills, self-care skills, ability to mobilize social supports,
problem-solving skills, etc). Problems in functioning develop when (a) stress in the form of life
events is introduced, (b) personal dispositions lead to heightened reactivity, and (c) the level of
coping skills is insufficient to address the level of reactivity (Brown, 1981; Skodol, Dohrenwend,
Link, & Shrout, 1990; Zubin & Spring, 1977). Often, the clinical presentation of a patient may be
suggestive of severe psychopathology from a medical model perspective, but may actually be the
result of a small shift in that patient’s stress-coping equilibrium, as exemplified by the following
clinical vignette.
A 34-year-old single mother of two children screened positive for depression in a medical exam
and was referred to the behavioral health consultant. Her depression score and clinical presentation
both indicated she was severely depressed. When asked if there had been a shift in her life over the
past 2 or 3 months, she gave the following report. Three months prior, she had been working both a
daytime and a nighttime job. Money was so tight that she couldn’t afford the gas to drive to work.
So, she had to walk approximately 30 minutes each way. After the daytime shift ended, she would
walk home, feed her children, and then walk to her other job at a fast-food establishment nearby.
About 2 months prior, she received a much-hoped-for promotion to manager at her daytime job,
along with a hefty pay raise. The increased pay allowed her to quit her nighttime job and also pro-
vided the gas money for her commute to work. When asked how she had coped before with the
pressure of being a single mom working two jobs, she recalled that the process of walking to and
from work had helped her get organized, reduce her stress level, and increase her general energy
level. When asked if she was still exercising each day for 30–45 minutes, she reported she had not
done any exercise since the promotion.
A medical model analysis of this patient would result in the diagnosis of “major depressive
disorder, single episode, severe.” A stress-coping analysis would conclude that a very basic stress-
buffering response (her daily walks) had disappeared from her repertoire, while to some extent her
stress level (being at home with her two young children) might have increased. After 2 months of
this “out of balance” lifestyle, she was unable to maintain an adaptive relationship between the
stresses of her life and how she took care of herself in the face of stress.
Theories of Change: Cure Versus Strategic Change

As should be obvious from the previous vignette, how one conceptualizes a mental health problem
leads directly to an assumption about what the intervention goal must be. If depression is an
“illness” that is characterized by a specific set of “symptoms,” then the goal of treatment is to
eliminate those symptoms and, inferentially, remove the underlying illness. This is the predominant
model of change for most primary care providers at the outset of training. I point out during
training that there are many potential problems with the “cure” theory of change. One problem is
that it flies in the face of evidence about the natural resting state of human existence. Rather than
being divine beings free of “issues,” mood swings, and dark moments, human experience seems to
involve highly variable mood states, frequent negative self-referent thinking, and an ongoing
struggle to acquire and maintain a sense of well-being. Is the woman in the vignette experiencing
an “illness” or is she experiencing the natural effects of a positive life shift in which she has not
made a necessary adjustment in her self-care strategies? A second major problem is that patients
with long-term psychological problems seldom get “cured.” They struggle with psychological
symptoms of one type or another for decades. Assessing whether treatment is “working” with such
patients based upon the presence or absence of symptoms is going on a fool’s errand.
In contrast, the key feature of the stress-and-coping approach is that even small changes in any
domain can produce symptoms of distress that can take on the appearance of a full-blown mental
disorder. Thus, the goal of treatment can be to reduce the impinging stressor, work on reducing reac-
tivity, or heighten any number of coping responses. Not only is there a vast literature linking stress,
coping, and social support to the development of psychopathology, but many evidence-based behav-
ioral interventions and brief therapies implicitly adopt this approach. The goal is not necessarily to
fix what is broken, but to equip the patient with the skills needed to reduce stress, cope with the
impact of stress, and/or increase social integration and support. The result is a model of change that
does not require heroic actions on the part of the patient or the provider. Rather, helping patients
make small, positive changes can have a tremendous impact. I train primary care providers to under-
stand that working with stress and coping repertoires may be more important than eliminating the
symptoms of mental illness. This type of change can actually be achieved without the need for
intensive, specialized services. Not surprisingly, behavioral health providers who have substantial
exposure to the brief therapies and time-limited, cognitive behavioral interventions resonate to this
message during training and will also tend to prosper in the primary care environment.
Primary care providers typically receive very little formal training in basic principles of behavior
change. During didactic workshops, they will candidly point out this lack of specialized training as
a chief reason they are not prepared to work on behavior-change issues with patients. The one
intervention they are trained in, and the one they feel most comfortable with, is the use of medica-
tions. As mentioned earlier, using medication is both quick and consistent with the biomedical
paradigm of mental disorders.
To be fair, primary care providers are faced with a daunting task: to deliver behavioral health
interventions in a 1-to-3-minute time frame within a comprehensive medical exam. Given the
enormous volume of patients seen in any given practice day, a poorly conceived behavioral health
intervention may cause the provider to be late for appointments the rest of the day. From this
perspective, it is understandable that primary care providers are leery of behavioral interventions
and are much more likely to reach for the prescription pad when time is tight. Giving a patient
medicine is a major practice management strategy in primary care. The act of prescribing a medi-
cine (even if it is not warranted) is a culturally accepted sign that the provider has listened and
responded to the patient’s complaints.
Fortunately, primary care providers know from experience that concrete, bite-sized functional
interventions can dramatically affect functioning, health, and the patient’s sense of well-being.
Indeed, the impact of such 2-to-3-minute interventions in medical practice is supported by clinical
research (Robinson et al., 1995). Establishing a better understanding of the conditions that promote
behavior change is a basic requirement of training for primary care providers. For example, most
primary care providers are receptive to the idea that selecting small, positive behavior change goals
has an incremental, positive effect on functioning. During didactic training, I might use vignettes
like the one above and then ask primary care providers to tell me what is wrong from a stress-
coping perspective and then what the behavior change target would be. The use of clinical vignettes
teaches both behavioral health and medical providers to apply the stress-coping model to conceptu-
alize a problem and then develop a “bite-sized” intervention that will work.
In the previous vignette, the behavioral health consultant worked with the patient to develop a
stepped exercise plan (i.e., start at two exercise periods weekly and then add one additional period
each two weeks, up to five). No antidepressant medication was prescribed pending the results of her
coping plan. She returned 2 weeks later reporting more than a 50% reduction in her depression
level and that she had spontaneously gone from two exercise periods in week 1 to four in week 2
because she felt so good after working out. The consultant recommended that she continue the
exercise plan, after consulting with the referring medical provider, and return in another 2 weeks
for a brief checkup. At that visit, her depression inventory score was in the nondepressed range, and
she did not meet diagnostic criteria for any depressive disorder. When primary care providers see
that something as simple as building an exercise plan is a legitimate intervention for major depres-
sion, the goal of delivering effective behavioral health interventions in a medical exam seems much
more achievable.
In most settings, primary care providers should look to the behavioral health provider for edu-
cation and guidance on behavior change issues. The behavioral health provider needs to know both
the evidence-based literature on treatments for various types of problems and to be conversant in
such topics as strengths-based intervention models, stages of change interventions, or motivational
interviewing, to name a few. In a basic sense, primary care providers are the world’s ultimate prag-
matists. If a behavior-change intervention works and its rationale is well understood, the primary
care provider will integrate it into routine practice. If a behavioral health consultant is going to help
reshape assumptions about behavior change, it is important to “walk in the shoes” of the primary
care provider and see patients for only 15–25 minutes. This experience will help the behavioral
health provider appreciate the challenges inherent in developing effective, tangible interventions in
a fast-paced session. The interventions that originate in very short visits will be far more relevant to
primary care practice than those developed in an hour. Without this type of role modeling, most
primary care providers will quickly return to an overreliance on medication treatments.
Therapist-Guided Versus Patient-Guided Change

The traditional mental health service model is an office-based, specialty model. A cardinal feature
of the specialist model (even in medicine) is that the specialist’s expertise is the active ingredient in
promoting a positive outcome. The patient is not expected to acquire or use the specialist’s knowl-
edge independent of the guidance of the specialist. For example, a thoracic surgeon does not expect
the patient to learn how to conduct heart-lung surgery. The patient’s job is to participate as the
recipient of the procedure, to follow the specialist’s recommendations, to follow up for required
medical examinations, and so forth. If the patient does all of these things, then the chances of
success are increased.
The analogy of the behavioral health provider as specialist breaks down on closer scrutiny. From
a stress-coping perspective, one can hardly claim that most behavioral health interventions are
highly specialized. Most of the strategies incorporated in mental health and chemical dependency
treatments have been available to and used by the community for decades. One only need examine
the self-help section of the local bookstore to support this notion. For example, Was the exercise
intervention with the depressed patient in the previous vignette really that different from having a
friend tell her that she needed do get out and do something to take care of herself? In most situa-
tions, the behavioral health provider possesses a degree that allows culturally sanctioned interven-
tions to be endorsed. This is powerful medicine, but it is not unique and specialized compared with
the skills required for open-heart surgery. If there is a distinctive benefit of “therapy,” it may be that
the process itself provides a structure for approaching and resolving problems, rather than avoiding
and exacerbating them. However, this benefit may be costly in other respects. Essentially, the
patient is required to participate in sequentially organized treatment sessions over time and the
therapist “releases” information in stages according to his or her perception of the patient’s readi-
ness to learn new strategies. This places the patient in a subordinate role where the therapist is
responsible for the transmission of key knowledge.
This service delivery model may work for providers, but it does not coincide with the prefer-
ences of patients. Primary care patients want advice, support, and the responsibility for managing
their own conditions. In this sense, the patient education model dominant in health care is not
philosophically organized to be consistent with the intervention models of various psychotherapies.
During didactic training with primary care providers, I try to draw an analogy between the exercise
plan created for the depressed patient and the formation of a self-management plan for a newly
diagnosed diabetic patient. Both involve educating the patient about the nature of the condition,
discussing the various types of self-management activities that will help the condition, and then
assisting the patient in developing a specific self-management plan that the patient will be responsi-
ble for implementing. The goal of such plans is to get the patient to practice new strategies outside
of the primary clinic in their native environment. In discussing clinical vignettes like the one above,
it is important to highlight that the active ingredient of the exercise intervention is not the 15 min-
utes spent with the behavioral health consultant or the medical provider. Rather, the active ingredi-
ent in behavior change is the extent to which the patient engaged in coping responses (i.e., exercise)
known to be effective in reducing depression. The goal of strategic interventions is to get the patient
to do something different in response to challenges that are being faced on a daily basis.
In primary care contexts, it is unusual for a behavioral health consultant to be in a long-term
consulting relationship with a patient. The goal of the consultant is to fully inform the patient
about self-management strategies available to address a particular life circumstance and develop a
“patient-centric” action plan. Pamphlets, classes, and brief consultative support visits replace the
therapeutic process. Most behavioral health providers struggle with these ultra-brief regimes, where
they cannot exercise immediate control over the flow of treatment. They are uneasy about shifting
so much responsibility for behavior change to the patient. However, evidence for the clinical
effectiveness and consumer acceptability of this approach is indisputable (Katon et al., 1996;
Robinson et al., 1996).
Attacking Myths and Misconceptions That Fuel Resistance

Although philosophical assumptions define whether the job of behavioral health in primary care is
“doable,” the mental health field has fallen prey to many myths about clinical assessment, how
effective working relationships are formed in therapy, and how therapy itself works. When
providing didactic training to behavioral health and medical providers, it is important that we
directly discuss these myths and misconceptions. Left unaddressed, these beliefs can impact the
provider’s level of confidence in the selected interventions.
Traditional Versus Functional Assessment Models

Most behavioral health providers spend 60–90 minutes in their initial meeting with a patient,
collecting a voluminous amount of information and developing a comprehensive treatment plan.
They are trained to believe that this level of detail is required to make accurate assessments and
deliver clinically competent care. When confronted with the idea that a new patient will be seen for
15–30 minutes, behavioral health providers will contend that it is impossible to accurately assess a
patient in this amount of time. What they do not understand is that there are no studies linking
much of the information obtained in the traditional mental health intake with improved clinical
outcomes. The most important and often least attended to component of an intake interview is to
figure out what the patient’s current problem is and to design a strategy to solve that problem.
Many studies have found that agreement on a definition of the problem to be targeted is a powerful
nonspecific predictor of positive outcome (cf. Garfield, 1994). It is highly related to the develop-
ment of an intervention that is viewed as credible by both the therapist and patient, another power-
ful nonspecific predictor of change. Unfortunately, a good deal of the traditional behavioral health
intake (i.e., relationship histories, family, work and educational histories, genograms) seems periph-
eral to this goal. It appears that the work requirements have expanded to fit the work pace of a spe-
cialty model of service. In obligatory fashion, the peripheral aspects of assessment become reified as
a standard of practice. As the old saying goes, the work will expand to fill the time!
Within the behavioral health industry, there are competing schools of thought about how much
information is needed about a patient in order to deliver effective treatment. Many popular
strategic intervention models emphasize that patients will readily provide information about the
most important components of their current and immediate past circumstances, if the therapist
provides the necessary session structure and avoids reinforcing certain types of time-consuming
therapeutic transactions (Budman & Gurman, 1988; De Shazer et al. 1986; Hoyt, 1991). A hallmark
of many brief therapies is the philosophy that it is not the patient’s problem that is causing
dysfunction, but rather the solutions that are being used to solve the problem. Within the brief
therapy framework, the information required for an effective intervention can usually be obtained
in 20–30 minutes. Although there may be cases that require more information gathering than is
possible in a 20–30 minute visit, this is the exception rather than the rule. It is also important to
remember that the behavioral health consultant is practicing in a medical team context in which
other medical providers have additional information and perspectives about a patient’s behavioral
health history. This information normally is not available in a mental health or chemical depen-
dency clinic unless there is an established history with the patient. It is striking how much corrobo-
rating information is available from other primary care team members; often they may have a
multiyear history a referred patient.
The Therapeutic Versus Team Relationship

The therapeutic alliance has been shown in many studies to be a strong predictor of both adherence
to treatment and positive clinical outcome. Far less well understood are the conditions that are both
necessary and sufficient for a therapeutic alliance to develop. Many behavioral health providers
believe that the strength of the therapeutic alliance is linearly related to the amount of time spent
with a patient. Therefore, spending less than the traditional amount of time with a patient damages
the therapeutic relationship and decreases clinical efficacy. Although there is a host of literature
supporting the importance of the therapeutic relationship as a predictor of clinical response,
there are no studies establishing this as a function of time spent with the patient. In other words,
rapport can be established within 5 minutes of the first encounter or never established in 20 one-
hour sessions. In fact, it appears that the quality of the therapeutic relationship is to some extent
independent of the amount of time the therapist and client spend in session (cf. Beutler, Machado,
& Allstetter-Nuefeldt, 1994). Finally, it is important to remember that almost all studies of the ther-
apeutic relationship have been conducted in the mental health specialty setting and the rules for
forming effective therapeutic relationships may not generalize to the primary care patients.
As noted previously, there are drastic differences in the gestalts of primary care and a mental
health clinic. One profound difference is that in primary care, the patient’s relationship is with the
health-care team, not necessarily with just one individual on the team. In primary care, there is a
conscious effort to substitute the single provider–single patient relationship with the team-patient
relationship. Clinical outcome studies with primary care patients clearly indicate that this model
produces lower dropout rates, better adherence to treatment regimens, and better clinical outcomes
(Katon et al., 1996; Mynors-Wallis, Gath, Day, & Baker, 2000; Mynors-Wallis, Gath, Lloyd-Thomas,
& Tomlinson, 1995; Robinson, Wischman, & Del Vento, 1996). Because of this feature, primary
care providers typically are more comfortable with the idea that the team relationship is just as
powerful as the 1:1 therapy relationship. They often are perplexed by the emphasis behavioral
health providers place on the 1:1 relationship because it is inconsistent with their direct experience
working in the team model.
More Therapy Is Better

Many behavioral health clinicians assert that patients with significant behavioral health issues can-
not possibly overcome these problems by participating in such brief team-oriented intervention
regimens. This is really a throwback to the controversy regarding the acceptability and efficacy of
brief therapy in general (Hoyt, 1991). The argument is that it takes time to build a therapeutic
relationship, to work through client resistance, manage transference, and eventually engage the
client in meaningful attempts at behavior change. The “dose-effect” literature (Howard, Kopta,
Krause, & Orlinsky, 1986) provides only modest support for this idea. Although nearly all the dose-
effect data are derived from studies of specialty mental health patients (making inferences to behav-
ior change in primary care settings an issue), it is clear that a great deal of behavior change happens
very quickly in psychotherapy. Specifically, approximately 50% of the total benefits of therapy are
realized before the completion of the eighth session (Howard et al., 1986). Indeed, many new
generation behavioral therapies emphasize important concepts such as acceptance rather than
change, as well as the notion that change may be a qualitative rather than quantitative process (see
Hayes et al., 1999; Hayes and Strosahl, 2004).
A second commonly held misconception is that consumers prefer longer-term treatment for
their behavioral health problems. This is the basic assumption of the fee-for-service model of
mental health private practice, but it is well documented in health services research that the average
psychotherapy patient will participate in four to six sessions of treatment. The psychotherapy
dropout rates in most mental health settings (i.e., patients who stop on their own without discuss-
ing it with their behavioral health provider) approaches 50% (cf. Garfield, 1994). Empirically
validated treatments in behavioral health routinely involve 12–24 hours of treatment, vastly greater
than most consumers are willing to tolerate. Evidence-based behavioral programs in primary care,
using far less session contact time, have produced clinical outcomes that are comparable or superior
to those in specialty treatment (Katon et al., 1996; Mynors-Wallis, 1996; Mynors-Wallis et al., 1995,
2000, Robinson, Wischman, Del Vento, 1996).
I have found it very important to talk about the active ingredients of therapy when training
primary care providers as well. Primary care providers have many stereotypic beliefs about what
goes on in the process of therapy and what the science says are the active ingredients of successful
therapy. In prior, often limited contacts with behavioral health providers, medical providers have
learned that the process of behavior change is very complicated and that it takes a specialist to do
the work. On the other hand, primary care providers know from experience that concrete, bite-
sized functional interventions can dramatically affect functioning, health, and sense of well-being.
In most settings, primary care providers will look to the behavioral health consultant for guidance
on these matters. If the behavioral health provider is resistant or negative about the power of strate-
gic or behavioral interventions, this will influence the medical providers on the team. On the other
hand, medical providers will aggressively pursue a brief behavior change model, if it is well under-
stood and advocated by the behavioral health specialist.
Practice-Based Core Competencies Training

When the didactic phase of training is completed, the goal shifts from equipping behavioral health
and medical providers with knowledge to providing them with the practice skills needed to apply
their knowledge. In this section, I will present a practice-based, core competencies training model
that has been used with significant success in several large-scale, primary care behavioral health
system initiatives.
During the past two decades, employee training programs in business and industry have shifted
from content-based to skill-based models. Essentially, content-based training attempts to convey
the intellectual knowledge about a specific task or role to the employee, usually in the form of train-
ing workshops, tutorials, and guided instructional curricula. These methods are didactic in nature;
they assume that the employee will incorporate intellectual knowledge and convert it to practical
application, once in the job context. The main problem with content-based training is that research
into its effectiveness is very equivocal. Attending a workshop has only a temporary effect on the
subsequent work behavior of the participant.
As a remedy for these disappointing findings, training experts have developed skill-based training
programs. In contrast to the emphasis on intellectual knowledge of content-based programs,
skill-based training emphasizes developing task fluency through structured and supervised
practice. Job shadowing, guided modeling, and in vivo skills training are typical skill-based training
methods. In medical training programs, these strategies are often collectively referred to as
academic detailing. Skill-based training divides job-related skills into core groups, known as core
competencies. The goal of training is to help the trainee acquire core competencies through guided
practice, with real-time modeling and performance feedback available from the teacher. In contrast
to didactic training methods, which have proven to be relatively ineffective in promoting lasting
changes in medical practice, skill-based training (academic detailing) has been shown to promote
stable changes in various medical practices (see Lin et al., 1995, for a discussion of these issues).
The dilemma facing behavioral health and primary care providers in an integrated model of
service delivery is similar to the problems businesses face when they retrain workers to function in
computerized work environments. New skills have to be acquired to function successfully, and it is
not feasible to re-educate the entire workforce; approaches must be developed that allow education
and skill development to occur quickly and cheaply. The core competencies training model
described in this section is an attempt to address this significant challenge. Table 1.2 highlights
many of the core competencies required of behavioral health and primary care providers practicing
in an integrated service delivery model.
Note that the “front end” of this training program involves exposure to the content of the
primary behavioral health model. If the provider does not understand the model at the conceptual
level, it is very difficult to conduct the hands-on training. On the other hand, all the concepts in the
world do not prepare the provider for the reality of sitting in front of a patient, gathering data in an
efficient way, and then picking an effective behavior change intervention. This requires in vivo
supervision from an expert trainer, often spaced over weeks or months, to promote fluency with the
primary behavioral health approach (see Dobmeyer et al., 2003, for a similar argument).
The core competencies to be targeted in training have some important features. First, there is
significant overlap in the practice skills required of behavioral health and medical providers because
they are working in a shared philosophical framework. At the same time, there are some distinct
differences resulting from different roles and responsibilities for each provider on the primary care
team. For example, clinical practice skills for primary care providers anticipate that roughly
1–3 minutes of a medical visit will be devoted to behavioral health issues. The behavioral health
provider may have 15–20 minutes of uninterrupted time with the same patient, leading to different
expectations of what can and should be accomplished during the longer visit. For example, the
behavioral health provider can conduct a more in-depth assessment and generate a more detailed
behavior change plan in a 20–25 minute session.
A second feature to note is that the primary behavioral health model requires both medical and
behavioral providers to change their practice styles. No miraculous changes are going to happen
through the simple act of placing a behavioral health provider on a medical team. Primary care
providers need to change how they conduct exams in a setting where the behavioral health consult-
ant is available in real time to assist with patient care. For example, behavioral chronic condition
programs may create a specific set of responsibilities for both the behavioral health and medical
provider. New core competencies might include knowing how to employ structured diagnostic and
symptom severity checklists, practice guidelines, behavior change plans, conjoint visits with
patients, and new charting practices. Space does not permit a detailed examination of each core
competency in the program, but it will be of value to briefly discuss each core competency domain
and how this training approach targets the skills of primary care and behavioral health providers.
Clinical Practice Skills

Clinical practice skills are required for effective, brief interventions that are medically appropriate
and can be supported and reinforced by other primary care team members. In general, this requires
primary care and behavioral health providers to quickly align with the patient, conduct rapid,
TABLE 1.2 Core Clinical Domains and Practice Competencies Required for Integrated Primary Behavioral
Health Care
Clinical Practice Skills
Identifies problem quickly and accepts patient’s point of view
Efficiently describes and employs biopsychosocial model of behavior change
Limits number of target problems consistent with strategic theories of change
Applies patient strengths and resources to identified problems
Uses patient education and home-based practice model
Focuses on functional outcomes
Interventions emphasize acceptance as well as first-order change
Evaluates client’s readiness to change and emphasizes client-driven change
Interventions are simple, racially and culturally sensitive, and supportable by other primary care team
members
Uses brief, culturally appropriate assessments and interventions
Shows understanding of relationship of medical and psychological processes
Shows knowledge of psychotropic medicines and adherence strategies
Understands evidence-based treatments and can develop primary care protocols
Shows understanding of behavioral medicine principles and interventions
Can apply health psychology concepts and interventions in prevention protocols
Ready to provide primary care lifestyle class or group care clinic alone or with a primary care team member
Practice Management Skills
Measures outcomes of behavior change plan at every visit
Uses 30-minute sessions efficiently*
Stays on time when conducting consecutive appointments
Uses community resource and social support strategies
Evaluates outcomes of interventions and develops alternative treatment when indicated
Uses intermittent visit strategy to support home-based practice model
Choreographs patient visits within existing medical services process
Uses flexible patient contact strategies (i.e., phone, letter)
Uses patient-care modalities designed to manage caseload (classes, group care clinics)
Coordinates triage of patients to and from external specialty services*
Consultation Skills
Understands distinction between consultation model and psychotherapy model*
Can explain role of consultant accurately to patient*
Focus is on referral question*
Provides feedback to referring providers on a same-day basis*
Tailors recommendations to work pace of medical units*
Conducts effective curbside consultations
Recommendations are concrete and easily understood by all primary care team members*
Consultations incorporate health and behavioral health factors*
Willing to aggressively follow up with health-care team members, when indicated
TABLE 1.2 (continued)

Leads efforts to develop clinical pathways for behavioral health conditions*
Focuses on recommendations that reduce primary care physician’s workload*
Uses prescribing psychiatric consultant appropriately
Documentation Skills
Documents BHC response to primary care physician referral question
Writes clear, concise chart notes indicating BH treatment plan, treatment response, and patient adherence to
homework
Gets chart notes and feedback to physicians on same-day basis
Chart notes are consistent with curbside conversation results
Protects sensitive and confidential information
Knowledgeable of reporting requirements for physical abuse, sexual abuse, and neglect
Team Performance Skills
Shows awareness of medical provider roles within the primary care team
Understands and operates comfortably within primary care culture
Frequently circulates through medical practice area to create top-of-mind awareness among primary care
team members*
Develops various strategies to build a consulting practice by dovetailing on common teamwork processes
Readily provides unscheduled services when required
Is available for on-demand consultations by pager or cell phone
Willing to provide brief educational talks during lunch hour meetings
Administrative Skills
Understands relevant policies and procedures from services manual
Understands and applies risk-management protocols
*Indicates core competency specific to the behavioral health provider; all others are shared competencies.
appropriate diagnostic and functional assessments, limit the scope of the target problem, and select
“bite-sized,” behaviorally oriented interventions that can be supported by any team member.
As should be obvious, the foundation for these skills is the ability to conceptualize behavior change
in stress and coping terms, to understand the interaction of medical and psychological processes,
and to shift to an intervention model that uses patient education and home-based practice in lieu of
frequent provider-patient contacts. Because of the formidable demand for behavioral health
services within the primary care population, behavioral health clinicians simply cannot afford to
engage in more traditional and time-consuming forms of assessment and treatment. Instead of
conducting extensive family, work, or psychiatric histories, the goal is to get into the “here and now”
with the patient. How is the patient functioning at work, with family, at church, or with friends?
How has the patient addressed problems like this before in life? What types of coping strategies is
the patient using now and with what success? The definition of what is an appropriate assessment
shifts from patient to patient, depending on the needs of the referring medical provider but, in gen-
eral, the focus of the assessment and subsequent behavior change plan is on improving the patient’s
current functioning.
For different reasons, primary care providers must learn efficient ways of generating an agreed-
upon definition of the patient’s problem and then selecting interventions that are limited in
scope. There is simply not enough time in a typical medical exam to get anything resembling
a comprehensive social or psychiatric history. The goal is to minimize the service burden associated
with managing the general health-care needs of a panel of 2,000–3,000 patients. The concept of
“working diagnosis” is applicable here. A working diagnosis allows the provider to treat the pre-
senting problem based on an incomplete set of data, then observe the results of treatment and
refine the diagnosis. Only if the patient fails to respond does the search for more comprehensive
assessment data begin (i.e., referral to specialists, specialty tests).
In general, behavioral health providers working in primary care need to understand empiri-
cally supported interventions and deliver them in a highly condensed fashion. Not only will the
number of contacts with the patient be smaller, but session times will be shorter as well. The first
requirement is to keep current on empirically validated treatments. This can be accomplished by
purchasing one of several excellent volumes devoted to this subject (i.e., Nathan & Gorman,
2002). In addition, the behavioral health provider needs to be an accomplished Web surfer,
accessing evidence-based-care Websites on a frequent basis. When delivering care in an evidence-
based chronic condition program, the same basic intervention principles apply as in a general
consultation. The main exception is that the number of interventions and frequency of sessions
may change. Instead of seeing the patient one to three times, as would be the case in the general
consultation approach, behavioral chronic condition protocol might call for four to six short
visits. For example, asking a patient with heightened stress levels to exercise on a regular schedule
is a commonly used intervention that can be implemented in a very short time frame. Regular
exercise is good for almost any person who is not medically constrained from doing so, and the
provider can plan on seeing the patient back in 2–4 weeks to review the success of the plan. How-
ever, if the patient is clinically depressed, the exercise goal might be only one component of the
evidence-based intervention program to be recorded on a standard depression management form
in the medical chart. This form in turn could be included in an interactive patient education
pamphlet on depression (see Robinson, Wischman, & Del Vento, 1996, for an excellent example
of this strategy). Subsequent 20-minute visits might expose the patient to other evidence-based
self-management strategies, such as personal problem solving, behavioral activation, cognitive
disputation, and so forth. Each session would result in the development of a new self-manage-
ment goal. Thus, the depressed patient might end the program with three or four specific self-
management goals, because the severity of the patient’s presenting problem warrants a higher
intensity of stepped care.
Given the frequency with which medicines are used in primary care, both medical and behav-
ioral health providers need to have an excellent grasp of functional psychopharmacology. It is
important to understand the pharmacokinetic bases of these compounds, important drug-drug
interactions, common side effects, and basic medical contraindications. There are several excellent
textbooks on psychopharmacology for nonmedically trained providers, and I usually encourage the
provider-in-training to purchase one. Another excellent way to stay current is to attend workshops
on psychopharmacology as well as lunches sponsored by the various pharmaceutical companies.
I train medical providers in particular to understand that their use of medications needs to be
consistent with clinical practice guidelines designed for primary care populations. Medicines are
both over- and underprescribed in primary care. They are often given to patients who do not have
the problem the medicine is designed to treat and often not given to patients who could benefit
from them. To correct this problem, I will often advise medical providers to use screening tools
designed to help define the nature of a presenting complaint more accurately. In some clinical set-
tings, brief screens for depression, alcohol and drug abuse, domestic violence, pain, and anxiety
states have been implemented as “vital signs.” The screens are administered before every medical
exam and the results are passed on to the medical provider by the support staff.
Given the pervasive problem of nonadherence to medicines, both primary care and behavioral
health providers need to be skillful in describing the complementary role of medicine and psycho-
logical interventions. Generally, it is useful to describe medicines as a short- and intermediate-term
treatment for improving functioning, so that the long-term solution of learning specific coping and
self-management skills can be accomplished. Both primary care and behavioral health providers
need to be acutely aware of and respond to patient beliefs and expectancies about medications that
influence both adherence and response to psychopharmacological treatment. When medication
occupies a major role in the management of a condition (i.e., antidepressants for major depres-
sion), behavioral chronic condition programs must contain strategies for systematic patient educa-
tion and risk assessment and management (Robinson, Wischman, & Del Vento, 1996). For
example, the typical primary care patient still believes that antidepressant medication is addictive
and that a lifetime regimen of medication treatment is required to manage depression. This type of
misinformation is easy to correct if the behavioral health and medical provider is sensitive to the
role that beliefs and expectancies play in determining adherence to medical care.
Practice Management Skills

Practice management skills are required to see 10–12 (and often more) primary care patients in a
practice day, to stay on time, to monitor clinical response in time-efficient ways, and to effectively
respond to the behavioral health needs of the entire population using population care strategies.
Effective practice management is absolutely essential for both primary care and behavioral health
providers, although the skills required for success may vary. For behavioral health providers,
perhaps the greatest challenge is the ability to organize and conduct 15-to-30-minute patient
contacts. This is a major focus of training in the core competencies approach. Most behavioral
health providers are trained to work in the traditional 50-minute hour that supports the specialty
model of behavioral health. By primary care standards, this is a luxuriously slow work pace. Most
primary care providers will have seen four to five patients in the same 1-hour time frame! To a large
extent, the behavioral health provider’s credibility is determined by the ability to work at the pace of
primary care and develop interventions that will work in the 1-to-3-minute time frame that is the
bread and butter of the medical exam structure. To routinely accomplish 15-to-30-minute sessions,
the behavioral health provider must reduce the emphasis on rapport building, eliminate unneeded,
time-consuming assessments, limit the problem focus, and stick with functional interventions. As is
the case within a brief therapy approach, the emphasis is on helping the patient develop practical
goal-oriented interventions.
Behavioral health providers that can master the 15-to-30-minute visit space typically do well
with the other core competencies. The interventions that fall out of such accelerated visits tend to
end up being small and concrete, precisely the type of strategies that are called for if one is using the
stress-coping philosophy. Consequently, I train the behavioral health provider to organize and
manage the 30-minute visit using the following time frames:
2–5 minutes: Introduce the service and the provider, link the general process to quality health
care, develop patient understanding/buy-in, and review previous home-based practice
results (in follow-up sessions).
10–15 minutes: Discuss current issues, identify problems, make differential diagnoses,
conduct functional analyses, assess what is working and not working, hunt for solutions
already in place, and create a shared problem definition.
5–10 minutes: Develop, justify, and troubleshoot a patient-centered intervention, set up
monitoring strategies, and agree to a follow-up plan.
5 minutes: Consult with primary care provider, implement any medical treatments, and chart
for the medical record.
The most common problem that behavioral health providers have is running late with one or
more patients, so that patients who have arrived on time for their appointments are required to
wait for unreasonable lengths of time. This requires both an awareness of the passage of time while
intervening with sometimes complicated clinical situations and acquiring skills that both prevent
falling behind and allow the provider to recapture time when running late. Any provider who can-
not effectively organize and conduct a 20-to-30-minute session will habitually struggle with staying
on schedule. This has a snowball effect throughout a day of practice. For example, if the behavioral
health provider runs 5 minutes late for each of the first six appointments, the provider will be 30
minutes late for the seventh appointment. Most behavioral health providers have no experience
with very high volume practice models like those common in primary care, so it should come as no
surprise that this is an area that frequently requires significant emphasis in training.
There are both effective and ineffective strategies for maintaining control of a busy practice sched-
ule. Effective strategies include anticipating a certain number of no-shows, scattering brief charting
and consultation slots throughout the daily schedule, or shortening a scheduled 30-minute, follow-
up visit to 10–15 minutes if the patient is doing well. Less-effective strategies include ending the visit
by requiring the patient to return for a second appointment to complete the assessment and inter-
vention planning process, implementing an intervention without gaining patient buy-in, or simply
referring the patient to some other community resource to get him or her out of the room.
For prescribing primary care providers, the least effective practice management tool is to precip-
itously reach for the prescription pad. In the busy world of primary care practice, the pill has
become a central practice-management strategy. This is compounded by the fact that very few
medical providers have any access to real-time behavioral health support in the context of their
daily practice. In essence, they are trapped in the room with a patient who may or may not comply
with nonverbal and verbal cues to end the medical visit. When this occurs, and it does on a daily
basis for most medical providers, prescribing a pill is the way to end the visit. It signifies to the
patient that the medical provider has listened and is doing something to help. The medical provider
learns that offering medicine can very rapidly conclude a visit that is spiraling out of control. The
problem is that this is a hit-or-miss solution. Some patients may actually benefit from the pill that
has been prescribed; others have little chance of a positive response. For example, research suggests
that only about 50% of depressed primary care patients who are prescribed an antidepressant actu-
ally meet diagnostic criteria for major depression (Katon et al., 1996). Patients with subthreshold
depressive symptoms are less likely to respond to medications. A second problem is that adherence
to medication is alarmingly low. As many as half of all primary care patients receiving a psychoac-
tive medication will discontinue on their own within 30 days (see Robinson, Wischman, & Del
Vento, 1996, for a more thorough discussion of this issue). In the world of primary care, it is very
difficult to track who is and is not taking medication as prescribed. Consequently, prescribing is a
double-edged sword. It works to manage the individual contact, but it is difficult to monitor adher-
ence and even more difficult to discontinue medicines in an appropriate clinical time frame.
Primary care providers are typically familiar with the practice implications of population-based
care. Patients are seen in brief medical visits that are organized around various practice algorithms.
The theory behind algorithmically stepped care is that, in most cases, the least intensive interven-
tion that is clinically indicated will work. It is only when a patient fails to respond to this first level
of care that a second level of care is initiated. This is a primary strategy for managing a scarce
resource, in this case the primary care provider’s time. At a certain point in the process of stepped
care, the complexity of the patient’s complaints exceeds the training level or time management
requirements of the primary care provider. This typically results in referral to a medical subspecialist,
who then takes on a significant role in managing the patient’s subsequent health care.
In contrast, behavioral health providers have little experience with the practice management
requirements of population-based behavioral health care. Typically, the strategies that work for
medical providers need to be translated into similar tactics and strategies for the primary behavioral
health provider. For example, a behavioral health provider will need to adopt a brief intervention
and team-based management approach that allows the needs of most primary care patients to be
addressed in one to three visits. Obviously, there may be patients who require more visits, and the
percentage of such patients varies dramatically according to the population being served. However,
even in an at-risk population, the behavioral health provider is responsible for managing resources
so that all members of the population have access to behavioral services. The conceptual shift and
skills required to adapt behavioral health practice to the demands of population care is a core focus
of the competency-based training program. This really involves a subtle combination of clinical
practice skills and a change in practice philosophy. In addition, this approach requires the
use of alternative, flexible, service-delivery strategies such as telephone follow-ups, psychoeduca-
tional classes, nursing-based interventions, and group medical care clinics (Kent & Gordon, 1997;
Robinson, Del Vinto, & Wischman, 1998). One central theme in my training is to have the behav-
ioral health provider understand that his or her “panel” is the entire population of the primary care
clinic. This means the behavioral health provider is a “scarce resource,” so the goal is to distribute
services to patients and consultations with medical providers in a way that maximizes the benefit
for the most patients. Each decision about when a patient is to return for follow-up and with what
intended effect must be weighed carefully. For example, having patients return in 1–2 weeks for
follow-up visits is the tradition in mental health specialty settings, but it can be disastrous in a high-
volume, primary behavioral health practice. When a provider is seeing 20–25 new patient referrals
per week, it only takes a month of practice management errors like this to create significant prob-
lems in the daily practice schedule.
For some behavioral health providers, population management philosophies can create stan-
dard-of-care concerns, founded on the belief that delivering abbreviated services is tantamount to
inappropriate treatment. It is important to understand that the traditional specialty practice model
defines the existing standard of care, and primary behavioral health is based in an entirely different
set of philosophies. Hence, the standard of care for primary behavioral health providers is not, and
should not be, defined by the practice of specialty mental health. This is analogous to holding pri-
mary care physicians to the same standard of care as cardiologists with respect to the assessment
and treatment of heart disease. Practice standards for primary behavioral health-care need to be
derived in the same way that standards of care for primary medical providers are derived.
As is true for the primary care provider, the primary behavioral health provider needs to effec-
tively manage the needs of the entire population to be served and to appropriately refer patients
who cannot be helped in this approach to the behavioral health specialty system. In other words,
just as the primary care physician needs the cardiologist’s special skills and expertise, so too will the
primary behavioral health provider need the specialty mental health specialist to intervene in more
difficult cases. Unfortunately, many chronically distressed, multiproblem patients who could bene-
fit from specialty mental health or chemical dependency care are simply not willing to receive these
services in the specialty setting. These patients are often among the first referred when a new, inte-
grated, behavioral health service is made available to the primary care team. Because of their level
of clinical need and provocative style of help-seeking, these patients can have a very disruptive
influence on a primary care center. The multiproblem medical patient must also be managed
within a population-care framework, otherwise, 5 or 10 such patients could consume all a behav-
ioral health provider’s time and schedule. In a population management model, the central focus is
not on providing long-term therapy to such patients, but rather is on managing unnecessary medical
utilization and forestalling further deterioration in the patient’s general functioning. This requires
the primary behavioral health provider to use a behaviorally oriented, case and crisis–management
oriented approach that may span months or years. This approach emphasizes forming a strong
team-based management plan that restricts the patient from using both excessive and unplanned
medical services. It may include any or all of the following strategies:
Create a yearly visit bank that the patient can manage but not increase.
Create specific crisis management protocols for unplanned medical visits.
Create a planned monthly medical visit schedule, do not permit unplanned visits.
Alternate planned monthly visits between the nurse, physician, and behavioral health
provider when the capacity of primary care team members permits it.
Develop a limited set of functionally oriented treatment goals that are consistently monitored
and reinforced during all medical contacts.
Engage in regular updating of the crisis management plan and functional treatment goals,
based upon the patient’s response.
The major philosophy in managing such patients is that no member of the primary care team
should have to absorb a disproportionate share of the service burden when addressing the plethora
of problems presented by the patient.
When providing interventions to patients using behavioral chronic condition care programs,
population-management strategies are even more essential. As Robinson states in chapter 2, the
goal of such programs is to coordinate the efforts of all medical team members with the aim of pro-
viding a consistent, structured process of care to all patients presenting with a specific behavioral
health issue. The primary behavioral health provider never adopts a specialty behavioral health
relationship with the patient. Rather, the visits with the behavioral health provider are interspersed
with medical visits, and the goal is for all providers to understand, monitor, and reinforce the
behavioral aspects of the patient’s health-care plan. In essence, any medical team member can func-
tion in the role of behavioral health provider with the patient. It is only through such collective
management that the medical team has any chance of addressing the vast demand for behavioral
health interventions in the primary care population.
Consultation Skills
Consultation skills are required for a behavioral health provider to provide clinically useful advice
about the nature of and interventions for behavioral health problems that are encountered during
routine medical exams. Primary care providers also need to develop specific skills that allow them
to maximize the impact of the behavioral health provider. This includes understanding what types
of patients might benefit from a behavioral health consultation, how to sell the patient on the value
of the service, how to frame an appropriate referral question for the behavioral health consultant,
and how to integrate behavioral health recommendations into the patient’s health plan.
The most important core competency for the behavioral health provider is a clear understanding
of a consultation practice and how it differs from a traditional psychotherapy practice. First, the
goal of the consultant is to answer a specific referral question generated by a referring medical
provider. This means that the consultant must be adept at “coaching” medical providers on how to
develop a specific referral question. Second, because the consultant’s job is to answer a specific
question and provide a set of recommendations, consultation episodes are typically brief and
focused. The consultant does not take over responsibility for treating the patient, but operates in a
temporary comanagement role with the referring medical provider. Another defining feature of
a consultation practice is that it is completely dependent on referrals from medical providers. This
means the consultant has to build the practice, a topic I will address in more detail in the next sec-
tion. A more basic premise is that the rate of referral is directly related to whether referring medical
providers believe involving the consultant adds value to the medical visit. If the consultant’s assess-
ments and recommended interventions are helping patients, the consultant will be used more and
more. Another important element of a consultation practice is that the referred patient must under-
stand the role of the consultant in relation to the referring medical provider. Because it is relatively
rare for patients to see a behavioral health provider in a primary clinic, the temptation is to assume
that the provider is there to deliver psychotherapy. This can lead to a different mind-set for the
patient and sometimes the referring medical provider. Thus, a major point of emphasis in my train-
ing is to make sure the behavioral health consultant clearly articulates the role of the consultant in
relation to the referring medical provider and the primary care team.
Generally, quality consultation both helps generate a set of strategies for the index patient and
teaches the medical provider how to address patients with similar presenting problems. The goal of
the behavioral health provider ultimately is to increase the ability of all medical providers to deliver
effective behavioral interventions. This is best accomplished through a consultation and brief
comanagement relationship between the behavioral health and primary care provider. Many behav-
ioral health providers have no graduate training in or practical experience with consultation
with medically trained providers. A major goal of the core competencies program is to help the
behavioral health provider acquire these skills.
When a patient is referred to the behavioral health consultant, there are two primary customers
to be served. One is the client, who will be the recipient of a set of brief consultative services.
However, the primary customer is the referring medical provider, who is asking for assistance in
such important areas as differential diagnosis, the relative merits of a drug, or behavior change
intervention. The primary behavioral health provider must focus on responding to the questions
raised by the referring provider. When the referring medical provider asks for an opinion about a
patient’s level of depression, the consultant must provide feedback that answers the referral ques-
tion. This does not prohibit the behavioral health provider from providing additional information
that may be of use in better understanding or treating the referred patient. At the same time, the
cardinal rule in consulting is that the referral question needs to be answered. On occasion, novice
behavioral health consultants are tempted to pursue clinical issues that may not be the central focus
of the medical provider. Although the medical provider is concerned about a patient’s depression
level and whether a specific treatment is indicated, the novice consultant might identify a history of
trauma related to sexual abuse as a child. The consultant might conclude that some type of in-
depth psychotherapy is needed to address the trauma and overemphasize this point while placing
less emphasis on the patient’s current mood functioning. In many such cases, the medical provider
will leave the consultative interaction less than satisfied. The medical provider may rightfully feel
that the referral question had to do with depression and related treatment recommendations, while
the consultant’s answer was focused on historical events that might be important in their own right,
but did not address the immediate treatment needs of the patient. In core competency training, I
always emphasize that the first job of the consultant is to answer the referral question. After that,
the behavioral health consultant can provide additional information and perspectives that enrich
the medical provider’s understanding of the patient.
Commensurate with the highly compressed time frame of a medical exam, the behavioral health
provider must generate a limited set of practical, workable strategies that fit the skills and
competencies of the referring provider. For example, recommending that the physician discuss
“introjected libidinal rage” with the patient is not likely to be helpful, whereas a recommendation
to ask the patient to participate in at least three social activities weekly to decrease social isolation
can easily be accomplished in a 2-to-3-minute discussion. Creating this level of simplicity, while
remaining consistent with the evidence-based care framework, is a major focus of core competency
development. Many behavioral health providers use psychological jargon in their professional
discussions with colleagues. They assume that mental health professionals speak a common
language, but the same assumption cannot be made about primary care providers. The behavioral
health provider needs to remember that most medical providers have limited mental health train-
ing and do not understand jargon or many of the nuances discussed in mental health staffings. In
general, even modestly specialized recommendations will tend to overshoot the sophistication,
interest, and skill level of most primary care providers. The primary behavioral health provider
must be able to extract the core principles associated with an evidence-based intervention, elimi-
nate jargon, and simplify the operational definition of an intervention. Further, any recommenda-
tions must be tailored to fit the skills, abilities, and interests of the referring provider and be
understood and supported by other members of the primary care team. One philosophy used in
core competency training is that a consultant actually has as many clients as there are primary care
providers in a medical clinic. Each provider has a different level of interest in and skill in dealing
with behavioral health. The consultant must understand and address each primary care provider
within these parameters.
Most consultations in primary care practice occur in what are commonly known as “curbside
consultations.” These are informal 30-to-60-second interactions during breaks in medical practice,
in which the behavioral health and primary provider discuss what to do with a patient that has been
evaluated by the consultant. Because of the busy work pace, such communications are brief and to
the point, and they convey a substantial amount of “core” information. Often, these curbside
encounters trigger important treatment decisions, such as whether the physician will start a patient
on a psychoactive medication. On other occasions, the primary behavioral health provider will
need to interrupt the physician during a medical visit to address an immediate medical service
issue. All of these encounters require brevity, an ability to discern relevant from irrelevant informa-
tion, and the ability to communicate directly and make clear and concise recommendations. Just as
the work pace of primary care emphasizes speed and efficiency, discussions about patient care need
to happen quickly and lead to positive results.
Often, integrated behavioral chronic condition protocols will provide additional aids to facilitate
the communication process, including such documents as goal-setting forms, intervention check-
lists, written relapse prevention plans, and patient progress-tracking systems. The goal is to stan-
dardize the way information is delivered to and shared among members of the primary care team
(see Robinson, Wischman, & Del Vento, 1996, for excellent examples of such communication
devices).
The pragmatic value of integrated behavioral health services is in large part determined by the
amount of work that is either saved or created by involving the behavioral health provider in the
routine process of health care. Behavioral health providers who find ways to reduce medical visits,
eliminate unneeded or ineffective treatments, or develop more effective ways to manage patients
will quickly be integrated into the medical team. Those who create additional work for referring
primary care providers will not be used over time. The goal of effective consultation and comanage-
ment is not only to create new intervention strategies, but also to eliminate interventions that are
less likely to be effective. As simple as this principle sounds, it requires the behavioral health
consultant to engage the medical provider in discussions about which treatments are likely to work
and which can be stopped. For example, many patients started on antidepressants are not likely to
benefit from that treatment, but they get medicine as a sort of “default” response. The intervention
picture with such patients can be greatly simplified by focusing on practical problem-solving goals
and stopping medicines for the time being. Many behavioral health providers, particularly those
with master’s level training, do not regard themselves as peers with medical providers, particularly
physicians. This can result in a reluctance to discuss assessment or treatment issues that might
place the consultant in the role of critic. The primary behavioral health provider must develop the
mind-set that primary care providers are overwhelmed with work, and they need help selecting
small, manageable intervention strategies. One way to achieve this goal is to be relentless about
reducing the number of interventions and taking on some of the burden of follow-up care. This
allows precious medical resources to be preserved, so they can be made available to more patients
in need.
Primary care providers, as “customers” of integrated behavioral health services, have to develop
the core competencies that will allow them to capitalize on these services. Most medical providers
have adapted their medical practice to a world in which there is no practical access to behavioral
health services in general, not to mention a behavioral health provider on the medical team. Conse-
quently, most medical providers develop a set of practice habits that may interfere with the upside
potential of integrated behavioral health services. As part of their core competency development,
medical providers need to open up their practices to discussions about behavioral health issues,
rather than take a “don’t ask, don’t tell” approach with patients. For many medical providers, taking
this step requires an almost complete revamping of their practice philosophy and style.
For example, most primary care providers have stereotypic notions of the behavioral health
issues that would be addressed by integrated behavioral health services. Most commonly, this
stereotype includes heavy utilization of medical services for depression, anxiety, and substanceabuse.
Very few medical providers think of behavioral health in a broad way that places it in a central role
in quality health care. When I provide core competency training to medical providers, this is the
“net” I want them to cast as they integrate behavioral health considerations in the exam room:
Behavioral health includes any behavioral factor that might affect a patient’s current or future
health status, broadly conceived as real or perceived physical health, emotional health, quality
of life and health habits, and behaviors that determine health risk.
Along with the traditional referrals (i.e., depression, anxiety, alcohol/drug problems), medical
providers are encouraged to refer such problems as sleep hygiene, weight management, smoking
cessation, headache management, disease management, job stress, marital conflict, parenting
issues, and high-risk sexual behavior, to name a few. In general, primary care providers need
to open up their routine medical practices to include the primary behavioral health provider in a
much wider array of human problems. Using the broadest definition of behavioral health,
one could make the argument that, just as every primary care patient has a health-care plan,
every patient should also have a behavioral health-care plan. For primary care providers, appreciating
the broad scope of behavioral health factors in general medicine is a key factor in providing effec-
tive, population-based behavioral health services.
When a primary care provider refers a patient for behavioral health consultation, it is important
to sell the patient on the service and the provider. It is important not to use stigmatizing words and
concepts (i.e., mental health, chemical dependency, therapist, counselor, psychologist) when discuss-
ing the potential value of seeing the behavioral health provider. Generally, terms associated with
traditional mental health will increase the “stigma level” of the transaction and lead to resistance.
For example, instead of using the word “therapist,” the medical provider should use terms such as
“team member” or “practice partner.” Instead of implying that the absence of a known medical
cause means that stress is responsible for chronic headaches, the medical provider must learn to
portray stress as an integrated physiological and psychological process. Developing this biopsycho-
social lexicon in medical providers not only requires hallway and lunch-time discussions about
mind-body medicine, but also written scripts, case vignettes, and role-playing exercises. I generally
place great training emphasis on how to introduce and describe the behavioral health consultation
service in a way that keeps the stigma level low and the patient acceptance rate high.
When the behavioral health consultant sees a referred patient, the existing health-care plan
for that patient should be modified to incorporate the recommendations made to the referring
medical provider. This allows every member of the medical team to understand, support, and mon-
itor the behavioral health plan. An important core competency for medical providers is to “close
the loop” on the consultation-feedback process by integrating the results into the medical treatment
plan. In a team-based management model, failing to do this can have dramatic negative conse-
quences. A nurse might be unaware of a plan developed by the behavioral health provider and phy-
sician because it is not in the patient’s medical chart. The nurse inadvertently recommends that the
patient engage in a type of self-management strategy that has been tried without success, so that the
patient now perceives that different recommendations are coming from different members of the
same team. Therefore, the patient may leave with the perception that members of the medical team
disagree about what the patient should do or that team members are not sharing information and
coordinating care. Both of these perceptions can be detrimental to the patient’s confidence and
participation in the behavioral management plan.
Team Performance Skills

Team performance skills allow the behavioral health clinician to integrate with and function effec-
tively as a primary care team member and to build a high-volume primary care practice. On the flip
side, primary care providers need to understand and integrate the special, complementary skills
that the behavioral health clinician brings to the medical team. In most cases, behavioral health
providers are nonmedically trained professionals (psychologists, social workers, counselors) enter-
ing a practice environment dominated by medically trained providers (physicians, physician assis-
tants, nurse practitioners, registered nurses). In many venues, the general stress of contemporary
primary care, the multitude of new initiatives that seem to emerge weekly, and the unrelenting
work pace make it difficult to maintain a focus on blending in the new member of the team. In
most cases, it will be incumbent upon the behavioral health provider to blend into the primary care
culture and build a vibrant practice.
Behavioral health providers must understand that the primary care medical setting is an alto-
gether different gestalt from traditional mental health settings. There is a different formal and
informal power structure; there are different medical disciplines represented on the team, and there
are different cultural norms. Most behavioral health providers have little if any experience with the
inner workings of a primary care team. One of the first tasks is to determine how the process of
team-based care is organized and who makes what types of decisions. Although physicians are
almost universally acknowledged as the formal leaders of a medical team, a nurse may be the de
facto decision maker, and the support staff may in actuality manage and control the daily work pro-
cesses. It is also important to understand how the rules of a primary care team differ from a typical
mental health team. A good example is the issue of privacy during visits. It is common in primary
care practice to be interrupted during an exam. A behavioral health provider who insists on not
being interrupted while in session is working contrary to the culture of the primary care team. In
general, behavioral health providers need to be flexible and open minded in their interactions with
medical team colleagues. During core competency training, I emphasize the importance of taking
additional steps to develop good relationships with both medical providers and support staff. These
are the individuals who can solve problems in real time, find the chart that has disappeared, or
locate an unused space in the exam room area when an emergency arises. To work effectively in
a primary care team requires a certain comfort level with the fast work pace, continuous multitasking,
frequent interruptions, and the ability to adjust to rapid changes in the daily schedule.
The next major goal in team-related performance is to develop a variety of strategies for “injecting”
the behavioral health provider into the daily practice routines of medical providers. To build
a referral-based practice, it is necessary to build “top-of-mind awareness” among all members
of the medical team. The eventual goal is to have medical providers conditioned to look for and
assess behavioral factors in their routine medical exams. I typically encourage behavioral health
providers to develop a “laundry list” of marketing strategies to create this top-of-mind awareness.
• Develop and distribute a monthly behavioral health newsletter highlighting the impact of
behavioral health factors in certain populations (diabetes, pain, headache).
• Develop a consultation service flyer that informs medical providers of how the service can
be accessed and what types of patients to refer.
• Shadow medical providers in practice to better understand their practice style and,
when solicited, provide feedback about interview style, assessment strategies, and inter-
vention options.
• Identify high-utilizing medical patients and develop behavioral health management plans
in consort with the medical providers.
• Schedule brief monthly meetings with each medical provider to review the status of jointly
managed patients.
• Secure “privileged time” in each provider staff meeting to review progress of the
consultation program and highlight recent referrals that demonstrate a new type of
problem to refer.
• Review schedules of medical providers each morning and use highlighter to indicate
patients that may be presenting because of behavioral health factors (e.g., headache, limb
and joint pain, gastrointestinal distress, insomnia).
• Build practice protocols that incorporate the behavioral health consultant in routine
processes of care (e.g., screening for medical adherence risk and depression in all newly
diagnosed diabetics).
• Adapt screening tools for common behavioral health conditions that are applied at each
medical exam or on a regular schedule.
• Develop exam room posters that screen for behavioral health issues that should be men-
tioned to the medical provider.
When an emergency situation arises in the context of daily practice, the behavioral health
provider needs to be part of the solution. If it is a psychiatric emergency, the behavioral health pro-
vider will see the patient at lunch or after scheduled work hours, if no other times are available. It is
contrary to team culture to refuse to provide an unplanned or unscheduled service, even if it means
disrupting an existing practice schedule. This type of team-oriented response, even though it may
be an inconvenience, will increase the likelihood that the behavioral health provider will be viewed
as a member of the medical team.
In many settings, the behavioral health provider will not be in the primary care practice setting
every day of the week. This may include situations where the provider is splitting time between a
specialty mental health clinic and the primary care clinic. It is important to ensure that all primary
care team members have immediate access to behavioral health support. Normally, a good strategy
is to carry a pager, a cellular phone, or a two-way radio. The process for making emergency contact
should be explained in both verbal and written form to all medical team members. The philosophy
is to encourage medical providers to call whenever the situation demands it. When a call for help
comes, the behavioral health consultant should immediately respond with at least a brief 2-to-3-
minute assessment on the phone to see whether the clinical situation can be addressed immediately
or whether a longer, follow-up call is needed. In practice, requests for emergency consultation are
rare, but a swift and effective response will be remembered for months.
Documentation and Feedback Skills

Documentation and feedback skills are required for the primary behavioral health provider to write
brief, to-the-point, evaluation summaries and progress notes in the medical chart and to protect
sensitive patient information from unneeded circulation. Although the majority of consultative
discussions with medical providers occur in the hallways, effective note-writing may be the only
communication vehicle to other members of the primary care team who are more distant in the
care-giving process.
The accelerated pace of primary care practice demands that consultation reports and other notes
in the medical chart quickly convey key assessment and intervention information. This is similar to
the process of curbside consultations, in which assessment information is pared to only the essen-
tial data needed to formulate a plan of attack. For example, the typical two-to-four-page intake
report generated by a behavioral health specialist would not be useful to most medical providers.
They have neither the time nor the interest to sort through a large body of information. In the typ-
ical case, chart notes should be no longer than one page, and often may be shorter. These notes gen-
erally should incorporate the following components:
A description of which provider referred the patient and what the referral question is.
A very brief summary of core symptom complaints and other stresses.
A very brief summary of the patient’s general functioning.
A summary diagnostic impression or problem statement.
A limited number of recommendations designed for all members of the team.
A description of the follow-up plan, if any, and what medical team members are to do during
subsequent patient contacts.
It is not unusual to address any one of these content areas in one or two sentences. The major-
ity of the note should focus on core symptoms, precipitating stresses, functional status, and the
behavioral interventions that are being recommended. All this should be written in concrete lan-
guage that does not contain jargon. In the majority of cases, writing the note will be preceded by
either a face-to-face consultation with the provider or a voice-mail message if the provider is not
available. Therefore, it is important that the note is consistent with the consultative feedback
already given.
On occasion, a patient may disclose personal and sensitive information to the behavioral health
provider that may not be appropriate for placement in the general medical chart. In general, medi-
cal charts are less-secure documents than the mental health or chemical dependency treatment
records maintained in specialty settings. The behavioral health provider must weigh the risks and
benefits of placing such information in permanent written form. In most cases, it is preferable to
communicate such information verbally to the referring medical provider and to write more
circumspect notes that present the core factors that led to recommended treatment strategies.
Dissemination of the Primary Behavioral Health Care Model: A Train the Trainers Approach
One of the major challenges facing larger primary care systems is how to disseminate the primary
behavioral health model across multiple sites, with differing local cultures and several different
medical teams. My experience as a trainer has taught me that it is important to maintain a core
consistency in the model of care, while allowing specific sites to respond to local population
requirements. Once the primary behavioral health model is spelled out in sufficient clinical and
administrative detail, it becomes immediately obvious that both behavioral health and primary care
providers need to receive skill-based training and support over time. The safe assumption is that
very few, if any, medical or behavioral health providers will be as effective as they need to be without
some form of standardized training. The goal of training is to help shape provider skills and behav-
ior to be consistent with the model of care. It is one thing to put behavioral health and primary care
providers in practice together. It is quite another to get them to practice together.
Faced with a similar challenge to ensure a consistent consumer experience with the delivery
ofnew products across multiple sites, national and multinational businesses have developed and
refined the “train-the-trainer” dissemination model. Essentially, the train-the-trainer model is
apositive example of the pyramid scheme. It involves creating a group of expert trainers and
distributing them strategically so they can train other lead employees, who in turn can train their
subordinates. In this model, dissemination of new products and service processes can happen
within months, often involving thousands of workers. The same principles have been used
to implement systemic changes in large, multisite health-care systems. By identifying and training a
group of local champions, health-care systems have successfully implemented medical
practice guidelines and desktop medicine initiatives, as well as visit process redesigns (Stuart et al.,
1991). Similarly, this basic technology transfer model has been used to implement the Primary
Behavioral Health Care Model in large primary care systems (see Dobmeyer et al., 2003, for
one such example).
For this dissemination model to work, both the clinical and administrative components of the
integrated program must be clearly defined. Normally the first step is to develop a detailed program
manual that documents both the clinical and operational characteristics of the primary behavioral
health program. Development of the services manual often reveals flaws in the model of care
design, legal or risk management issues, and gaps in administrative infrastructure. In the case of
integrated behavioral care programs, the process of program definition might involve conducting
pilot tests of patient education pamphlets with consumer focus groups and determining if assess-
ment tools and standard treatment forms are “primary care provider–friendly.” If these issues are
not addressed in the initial design process, then they will surface in unpredictable ways once the
program has gone “live.” Typically, problems that arise once a program is up and running do not
lend themselves as readily to rapid resolution, so the goal is to use appropriate planning to avoid
these problems. Further, the services manual is used as a living, breathing document designed to
help medical and behavioral health providers to quickly access important clinical and administra-
tive information (e.g., practice guidelines for chronic pain patients, billing codes, staffing ratios).
Once the integrated care program has been thoroughly articulated, it is possible to define the
core competencies required for providers to implement the new model of care. As was previously
noted, the core features of the model of integrated care will help highlight the core competencies
required of medical and behavioral health providers. This, in turn, allows administrators to take the
appropriate steps to supply needed training through a variety of methods.
Central Role of the Mentor–Trainer

The key player in this dissemination model is the mentor, or champion, who is responsible for shap-
ing, monitoring, and maintaining the core competencies required for behavioral health and medi-
cal providers. Thus far, this chapter has focused exclusively on the skills and abilities that primary
care and behavioral health providers must acquire in order to implement a primary behavioral
health program. When dissemination across a system of primary care sites is the goal, the focus of
training turns to ensuring that trainers demonstrate the following abilities:
• Significant clinical proficiency in the core competencies required in the primary

behavioral health-care model.
• The ability to help trainees understand the model and learn core competencies using both
didactic and hands-on methods.
• Positive interpersonal attributes that allow the trainer to form a mentoring relationship
with the trainee over time.
A mentoring relationship is not simply established by designation. The mentor must earn
the trust of the trainee, deliver both negative and positive feedback in a way that generates
behavior change, and act as a “cheerleader” to enhance the trainee’s motivation to excel. On a
trainee-by-trainee basis, the mentor is responsible for identifying the best methods for disseminat-
ing skills over the short, intermediate, and long term. Effective mentors are willing to create clear
performance expectations, model the behaviors desired, and create a sense of “can do” confidence in
the trainee. During clinical proctoring and supervision, an effective mentor individualizes feedback
and looks for “trainable moments.” These are times when the trainee is open to receiving new
knowledge or is looking to acquire or modify practice skills in a positive direction. Most providers
come into primary care practice with a set of strengths and weaknesses. It is important in mentoring
to help the trainee become aware of existing strengths and modify them to fit the demands of pri-
mary care practice. It is also important to examine how weaknesses are going to be corrected
through a targeted learning process. Successful mentoring is a long-term undertaking, and trainees
must accept that they will have periodic contact with the mentor over months, if not years.
Cotraining Medical and Behavioral Health Providers

In this chapter, I have discussed the many ways that primary care and behavioral health providers
will have to alter practice habits to make integrated care a success. Although the modifications may
be different, the one binding similarity is that this constitutes a major paradigm shift for both
disciplines. Often, team camaraderie is built by going through a difficult change together and, for
this reason, it is important to avoid segregating behavioral health and primary care providers in the
process of training. Just as it is bad practice to design an integrated-care system without the partici-
pation of all provider groups, it is equally misguided to focus training on one provider group alone.
Generally, the best results occur when primary care and behavioral health providers go through the
experience of service integration together. This might involve such exercises as having medical and
behavioral health staff members craft a patient brochure that explains the integrated care philosophy
of the medical team. Another activity might be to develop and role-play referral “scripts” so that
medical providers become more efficient at handing the patient off to the behavioral health con-
sultant. Many of the teaching methods in the core competencies approach are ideally suited for this
type of conjoint training. For example, case vignettes can be more interesting when both primary
care providers and behavioral health specialists are responding to the same stimulus piece. Best
practice videotapes might include interactions between medical providers and patients demonstrat-
ing the best ways to frame a behavioral health issue in a nonstigmatizing way.
In the real world of primary care practice, time is a scarce commodity, and time-intensive train-
ing experiences are hard to arrange. The focus of any in vivo training program should be to take
advantage of existing work processes as opportunities to deliver competency training. This means
that exercises such as script development, guided case discussion, and best-practices training need
to occur in the context of weekly staff meetings or medical team meetings. On the other hand, the
overwhelming temptation in the busy world of medicine is to short change the training process
resulting in an inadequate grasp of the primary behavioral health philosophy within the medical
team. In any integrated care initiative, senior leaders need to remind themselves, as well as their
managers, team leaders, and staff, that adding behavioral health services is an investment; it is not
simply a luxury. Part of this investment is to carve out the time necessary to optimize the chances
for success.
Graduate Training and the Future of Integrated Care

Obviously, the root cause of the need for field-based retraining is the failure of graduate programs
in behavioral health and general medicine to properly prepare their students for what awaits them
in the real world. Academic training programs are bastions of both regressive and progressive
forces. Although many of the most innovative medical and psychosocial treatments have been
discovered in these contexts, the same programs routinely produce professionals that are ill
equipped for the contemporary health-care environment. We still have graduate training programs
in clinical psychology that are preparing students to work in the office-based, fee-for-service,
private-practice model in a world that is largely dominated by managed care! Many training pro-
grams fail to properly train their students in how to negotiate managed-care contracts or to use
procedure codes that are required for insurance reimbursement. With a few notable exceptions,
most medical training programs do not adequately prepare residents to address behavioral health
factors in general health care. Most mental health training programs appear to be oblivious to the
primary care system in toto!
There are many ways graduate training programs can prepare behavioral health professionals for
the primary care environment. Coursework should include basic anatomy and pathology, detection
and treatment of acute and chronic disease, and the behavioral manifestations of medical illness.
Graduates should be exposed to functional psychopharmacology, behavioral medicine, and health
psychology. Some rudimentary exposure to public health and epidemiology would better help
behavioral health providers understand the central precepts of population-based care. Clinically,
students need to learn functional assessment skills, brief intervention strategies, and how to provide
consultation to other professionals. Requiring internship and postdoctoral experience in primary
behavioral health care should be a core element of all behavioral health training programs.
Within general medical and residency training programs, there are two basic deficits in the
behavioral health training medical students receive. First, the behavioral health training rotations
are too short, often involving 3 months or less of in vivo training. If integrated primary care is to
succeed, medical schools must stop the abysmal practice of undervaluing the behavioral health
component of general medicine. It is ironic that many of the same physicians who teach evidence-
based care so brilliantly when it comes to the medical assessment and treatment of disease, then
proceed to systematically ignore the evidence base on the necessity of treating the behavioral
sequalae of those same diseases. Medical schools must allocate more didactic coursework and resi-
dency training time to the assessment and treatment of behavioral factors in general health care.
Instead of implicitly or explicitly communicating that the behavioral health rotation is the least
important part of medical training, the message should be that medical care and behavioral care are
integral parts of general health care. One cannot be an effective health-care provider without being
competent in both realms.
A second shortcoming is that the behavioral health scientist model that has been adopted in
most family practice residencies is basically ineffective. The behavioral health providers functioning
in these roles are not teaching the behavioral health skills required for success in the field. Few
behavioral health specialists have prior experience working in the primary care milieu and tend to
teach and role-model traditional mental health strategies that simply do not fit the real world of
primary care. Medical and nursing students are then graduated into the professional sector, only to
discover that their mental health “tool kit” is woefully inadequate. Rather than teaching arcane
interviewing strategies designed to build rapport with the patient, behavioral health specialists
should teach the skills required to assess and intervene with behavioral problems in 2 to 3 minutes.
Didactically, medical students need less exposure to the medical model of mental illness and much
more education in behavioral medicine, health psychology, brief strategic therapy concepts,
cognitive behavioral therapy, evidence-based interventions, and full-spectrum psychopharma-
cology. In general, medical providers need to develop an individually tailored, flexible tool kit for
understanding the role of behavior factors in all aspects of general medicine.
Until the training institutions take responsibility for developing professionals who can under-
stand and work in integrated service models, we will be forced to retrain these professionals in the
field. There are some encouraging developments in this regard. Brantley and Jefferies (2000)
describe a combined clinical psychology internship and family practice training program housed at
Louisiana State University. This program is designed to prepare psychologists and physicians for
integrated primary care. The program involves a fully integrated curriculum that provides extensive
cross training in common areas of care, in addition to exposing students to more advanced aspects
of each discipline’s professional tool kit.
The U.S. Air Force psychology residency program now requires all predoctoral psychology
interns to undergo at least one 3-month rotation in primary care (Dobmeyer et al., 2003). Interns
are systematically trained using the core competencies training approach described in this chapter.
Achievement of a minimum standard of proficiency in the core competencies is a basic expectation
of the training rotation. These trained professionals are subsequently deployed to Air Force primary
care sites around the globe, supported over time by their residency-based mentor–trainers.
A highly innovative clinical psychology training program at the University of Nevada, Reno,
offers graduate students the option of enrolling in a training track in organized systems of care. The
courses offered in this track teach psychology students the basic principles of health economics,
epidemiology, population medicine, and performance benchmarking/program evaluation. Field-
based training experiences allow students to deliver clinical and research services in primary care
and hospital-based settings. The goal of the training curricula is to prepare psychologists to operate
effectively in the integrated health-care environment of the future.
Role Differentiation Among Behavioral Health Disciplines

A final issue that needs to be addressed in the era of integrated care is how to differentiate the roles
of various mental health disciplines. An all-too-common notion within general medicine is that all
behavioral health providers are essentially interchangeable, regardless of their training background
or degree. Which behavioral health discipline (if any) is best suited to work in the primary care
setting? With the growing popularity of integration, this issue is likely to be more on the front
burner than the back burner, and most medical administrators will candidly admit that they have
limited experience with these types of personnel questions. In general, administrators obtain
fragments of information from the behavioral health industry where, for cost containment reasons,
managed care companies have created the impression that all nonmedically trained behavioral
health providers are essentially interchangeable. The perception that “one size fits all” is also
reinforced by turf and guild issues within the behavioral health industry that have more to do with
market positioning than a rational analysis of the issues.
One might approach this question in the following way. If no link exists between the type and
intensity of training and the resulting skills of the provider, why do separate schools of social work,
psychology, psychiatric nursing, and psychiatry exist in nearly every university or college that is
large enough to support such training programs? If there is no difference between a social worker
and a doctoral-level psychologist, then why bother train psychologists? This ongoing debate is quite
mystifying to primary care providers, who work in a team model and readily accept role
differentiation as a basic requirement for effective teamwork. It would be a rare event indeed for an
advanced-practice nurse to claim to have the same professional skills as a general physician. Yet, this
type of reasoning is used every day to equalize a social worker and a doctor of psychology.
Ultimately, it is the responsibility of both behavioral health professionals and medical administra-
tors, not only to reject this homogenization, but also to work diligently to identify the unique
contributions of each discipline in the primary care milieu. This will allow behavioral health
providers to comfortably work within their scope of practice while allowing the primary care team
to benefit from the diverse skill sets represented in all the behavioral health professions.
Summary
In this chapter an attempt has been made to articulate the training issues associated with the
integration of primary care and behavioral health services. As should be obvious, the integration of
primary care and behavioral health services is better conceptualized as a system redesign. It is not
merely adding a new service to the primary care milieu; it more accurately reflects a rethinking of
the goals and process of general health care. This means primary care and behavioral health
providers have a very basic role to play in determining the structure and function of the integrated
systems of the future. In the world of everyday health care, it will be impossible to escape the
practical implications of rejoining the mind and the body. Although behavioral health providers are
often the initial targets of core competency development, there are equally fundamental changes in
the skill sets required of health-care providers. Perhaps the most important implication is that good
intentions alone will not make integrated primary care successful. It is only by taking a systematic
approach to identifying the skills required for success and developing cost-effective training
strategies that the potential benefits of integrated care can be realized.
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Chapter 2
Adapting Empirically Supported Treatments to the
Primary Care Setting: A Template for Success
PATRICIA ROBINSON
Primary care physicians and other primary care providers, including physician assistants, nurses,
and clinical pharmacists, provide a great deal of care to patients suffering with mental disorders
(Shapiro, Skinner, & Kessler, 1984). On average, primary care physicians spend 12.1 hours per week
(23.1% of a 52.8-hour workweek) providing direct treatment for psychiatric conditions (Howard,
1992). More than half of the mental health services in America are delivered in the primary care
setting (Knesper & Pagnucco, 1987; Magil & Garrrett, 1988), and at least half the depressed people
who receive mental health care do so through their primary care provider (Narrow, Reiger, Rae,
Manderscheid, & Locke, 1993). Regier et al. (1978, 1993) described the situation well when they
referred to the primary care system as the “de facto mental health system” in America. Collectively,
the number of patients seeking care for behavioral health problems in the primary care setting is
dramatically larger than the number seeking care in mental health settings (Strosahl, 1996a),
and this number is likely to increase as we move further into the new century. Current managed
health-care trends favor gatekeeper models that direct patients toward primary care providers who
can then assess the appropriateness of various specialty referral options (Hoy, Curtis, & Rice, 1991).
Perhaps more importantly, the initial outcome studies of primary care–based behavioral health
interventions suggest that patients report higher levels of satisfaction when their treatment is deliv-
ered in primary care (Katon et al., 1995, 1996). Further, cost effectiveness analyses have indicated
that the expenditure of behavioral health resources results in greater value (i.e., degree of clinical
improvement relative to the cost of delivering treatment) in the primary care as compared with the
mental health setting (Von Korff et al., 1998).
Patients are comfortable in the primary care setting for several reasons. Many patients have
ongoing relationships with primary care providers. These relationships often precede the
development of significant psychosocial stresses and behavioral disorders. Patients see providers as
capable of providing a big-picture perspective during difficult periods of development. Further,
primary care providers often provide services to multiple members of a family and may function as
important advisors on family matters. Some patients, particularly older adults, prefer the primary
53
care setting because they feel less stigmatized in seeking care from a physician as opposed to a
mental health provider (Robinson, Wischman, & Del Vento, 1996).
Although epidemiological and health services research suggests that there are many patients in
need of psychological interventions in primary care, little has been written to guide behavioral
scientist practitioners in the development and dissemination of primary care–based protocols that
incorporate efficacious interventions. Unlike the traditional mental health treatment setting, the
primary care setting employs a population care model. Consequently, treatments in primary care
are brief, focused, and rely on patient education and self-management strategies. In a typical year,
80% of all persons in a primary care catchment will have at least one ambulatory outpatient
medical visit. In contrast, behavioral health services are accessed by only 3–7% of a catchment in
any given year. This results in radical differences in the service delivery culture. Primary care
providers may often see 30 or more patients a day in 10-to-15-minute appointments. The typical
behavioral health provider sees six to eight patients a day in 50-minute appointments.
There is a host of primary care service delivery structures that supports a high-volume public
health model. These include the use of wellness and prevention visits, algorithmically based
stepped care, team-based patient management, patient education, and an emphasis on home-based
self-management. Most of these strategies are foreign to traditionally trained mental health
providers. If behavioral scientists and practitioners are to bring the most efficacious psychological
interventions to primary care patients, they must tailor protocols so that they are supportive of
primary care provider skill strengths, the expectations of primary care patients, and the basic
philosophy of primary care.
In 1995 a task force of the American Psychological Association (APA) Clinic Division issued
three reports on dissemination of psychological procedures. These reports identified a number of
psychological interventions as empirically supported treatments (ESTs). The efforts of the APA
occurred in response to a broader movement known as evidence-based medicine (Sackett,
Richardson, Rosenberg, & Haynes, 1997), which began in the United Kingdom. Psychologists in the
United Kingdom have been leaders in identifying ESTs, and they promoted the work leading to
publication of What Works for Whom? (Roth & Fonagy, 1996). The Clinical Psychology Division of
APA approved creation of a standing committee charged with ongoing evaluation of efficacy and
effectiveness of psychological interventions in 1999. Their most recent report is of great value to
behavioral health providers who plan to implement efficacious psychological interventions in the
primary care setting (see Chambless & Ollendick, 2001).
The Chambless and Ollendick (2001) report specifies levels of empirical support for specific
conditions. For adults, well-established treatments for various anxiety disorders include cognitive-
behavioral therapy (CBT), exposure, applied relaxation, exposure response prevention (for
obsessive-compulsive disorder (OCD)), and stress inoculation. Community reinforcement,
motivational interviewing, behavioral marital therapy plus dissulfinam, and social skills training
with inpatient treatment are well-established treatments for alcohol abuse and dependence. For
depressed adults, behavior therapy, brief psychodynamic therapy, CBT, psychoeducation,
reminiscence therapy (for mild-to-moderate levels), behavioral marital therapy (for those with
marital discord), and interpersonal therapy are well-established methods. Behavioral family
therapy, social-learning programs, and social-skills training are highly efficacious interventions for
schizophrenia that can be adapted for implementation in the primary care setting.
There are numerous efficacious psychological interventions for health-related problems. For
example, behavior therapy and cognitive therapy have well-established efficacy for anorexia, and
CBT is a well-established intervention for binge eating disorder and bulimia. For chronic pain, CBT
is highly efficacious, and, for headache, behavior therapy meets the criteria for the well-established
level of evidence. Multicomponent CBT is highly efficacious for rheumatic disease pain and
Adapting Empirically Supported Treatments to the Primary Care Setting • 55
smoking cessation. Behavioral interventions applied at the environmental level for behavioral
problems are efficacious treatments for dementia.
Chambless and Ollendick (2001) report a variety of efficacious treatments for relationship-
related problems for which patients frequently seek primary care. For example, behavioral marital
therapy has strong efficacy support for patients with marital discord. CBT and behavior therapy are
effective for several types of sexual dysfunction. Social-skills training is well established as a
treatment for avoidant personality disorder. For geriatric caregiver distress, psychosocial interven-
tions are highly efficacious.
The most effective empirically supported psychological treatments for children have great
importance in primary care because of the prevention potential inherent in the primary care
setting. These include behavioral parent training for attention deficit hyperactivity disorder and
CBT for distress due to medical procedures. For conduct disorder, cognitive behavioral therapy,
cognitive problem-solving skills, functional family therapy, multisystemic therapy, videotape-
modeling parent training, and parent training based on living with children (for both children and
adolescents) are interventions meeting standards for being well-established treatments. Behavior
modification is highly efficacious for encopresis and enuresis. For phobias in children, participant
modeling, rapid exposure (school phobia), and reinforced practice are highly effective. Contin-
gency management is effective for undesirable behavior associated with pervasive developmental
disorder. For the high-impact condition of psychophysiological disorder, family therapy is an
efficacious treatment. Finally, relaxation with self-hypnosis is a highly efficacious treatment for
recurrent headaches, which is common among young primary care patients.
Although the APA task force reports are helpful to clinical providers and generally well received,
some writers (e.g., Elliot, 1998) have criticized them for their focus on the efficacy of treatment in
randomized clinical trials (RCTs) and their relative lack of emphasis on effectiveness (i.e., whether
the ESTs work in real clinical practice). There are numerous effectiveness trials in progress that will
help clinical providers further select the most viable treatments, and some of these effectiveness trials
are being conducted in primary care settings. Related to the efficacy and effectiveness debate is the
controversy about clinician adherence to manualized protocols versus development of individualized
treatment protocols. Available studies do not provide strong support for one approach being better
than the other (see Emmelkamp, Bouman, & Blaauw, 1994; Jacobson, Schmaling, Holtzworth-
Munroe, Katt, & Wood, 1989; Schulte, Kunzel, Pepping, & Schulte-Bahrenberg, 1992), and in
primary care adaptations, clinicians need to be prepared to work from manuals and to provide
individually tailored interventions.
This chapter introduces readers to key concepts that underpin the adaptation of ESTs to the
primary care context. These include understanding the unique characteristics of the primary care
system, the principles of population-based care, and the use of evidence-based medicine in the
primary care setting. The Primary Behavioral Health Model (Robinson et al., 1996; Strosahl, 1996a,
1996b, 1997, 1998) will be examined. This model holds promise as a service delivery platform for
ESTs. The Primary Behavioral Health Model has already demonstrated clinical utility in defining
and guiding adaptation of ESTs for treatment of depressed primary care patients (Katon et al., 1995,
1996; Robinson et al., 1997). Finally, a functional and structural template will be presented for
building EST-based, population-specific protocols and pathways for primary care.
The Primary Care Setting

Primary care physicians are generalists committed to improving the health of all members of a
community. In the United States, primary care physicians include family practice physicians, pedia-
tricians, general internists, obstetricians-gynecologists, and general practitioners. The generalist
nature of the primary care setting requires providers to play multiple roles in the health-care
system. These roles include being direct providers of treatment for the majority of health problems,
case managers regarding chronic medical health conditions, and gatekeepers who determine patient
referral for specialty services.
The primary care setting and patients seen in this setting differ significantly from the mental
health clinic and clients seen in this traditional health-care setting. Further, primary care patients
may differ significantly from the research subjects who participate in studies that define EST.
Behavioral health providers new to the primary care setting are more likely to be successful when
their initial and ongoing efforts reflect an appreciation of the following five features of the primary
care setting: primary care is diverse, it is medically oriented, it is driven by psychosocial factors, it is
fast-paced and immediate, and it is “primary.”
Primary Care Is Diverse

Primary care is the melting pot of the health-care delivery system. Primary care providers see mem-
bers from every socioeconomic, racial, and ethnic group. They see patients in all stages of develop-
ment—from the first moment of life to the last. Their patients suffer from a wide variety of acute
and chronic diseases, as well as behavioral health problems. In a day’s work, they may see patients
who are mildly distressed and patients who are psychotic. The range of behavioral health issues
seen in primary care is truly remarkable. For example, it has been well established that the higher
utilizers of primary care often have substantial mental health and chemical dependency problems.
A substantial subgroup of high utilizers is clinically depressed (Katon et al., 1992), while another
sizable group suffers from co-occurring mental, substance-abuse, or dependency disorders. Com-
mon mental disorders in primary care include depressive disorders, anxiety disorders, alcohol
and other substance-abuse and dependence disorders, somatization disorders, and eating disorders
(Spitzer et al., 1995). Other disorders of concern in primary care include high acuity disorders,
which are less common, but require intensive service. These include schizophrenia and other axis-
one and -two disorders with psychotic features, as well as pain disorders associated with psycholog-
ical and medical factors. Among children, high-prevalence disorders include attention deficit
disorder, sleep disorders, conduct disorders, and depressive disorders. Along with patients who
meet the criteria for a mental disorder, there are at least as many and probably more that are
affected by the stress of medical illness, social disenfranchisement, job loss, economic hardship, or
relationship problems (Robinson et al., 1995). The daily life of a primary care provider involves not
just addressing the diverse health-care needs of primary care patients, but also an incredible range
of psychosocial issues as well.
Like their patients, primary care providers are also diverse. Primary care providers vary in prac-
tice styles and interest and specialization areas. Older primary care physicians tend to have older
patients, while younger doctors tend to attract younger patients (Robinson et al., 1995). Provider
panels vary in composition and size, and this is reflective of the practice setting and provider
interest and skill areas. Some providers deliver babies and provide care for numerous young
families, while others serve a large group of diabetics. Some providers enjoy treating patients with
mental disorders, while others have little interest in this area. Primary care clinics also vary signifi-
cantly in accordance with their organizational structure, with some emphasizing team-based
management (Taplin, Galvin, Payne, Coole, & Wagner, 1998), while others employ a solo practi-
tioner model (Rivo, 2000).
Primary Care Is Medically Oriented

Given a highly diverse group of patients, primary care physicians are challenged to diagnose and
treat myriad medical problems on any given day. In the medical setting, interview strategies and
level-of-care assignments are made quickly, and the tendency is toward ruling out medical
conditions and attempting to describe presenting complaints in biomedical terms. This reflects
preparation and training for primary care providers who can readily explain the medical basis of
psychological symptoms (e.g., depression related to hypothyroidism) and assess the physical
symptoms related to depression more thoroughly than the psychological ones. Primary care
providers are trained to evaluate the whole person. Predictably, they are more likely than psychia-
trists to give physical exams, neurology exams, and to obtain multiple lab tests (Epstein, 1995) and
prescribe psychotropic medications differently from their psychiatrist colleagues (Beeardsley,
Gardocki, Larson, & Hidalgo, 1988).
Primary Care Services Are Driven by Psychosocial Factors

In contrast to the biomedical orientation of most primary care providers, patients frequently seek
health care because of psychosocial stresses. In fact, most primary care patients present with symp-
toms that do not meet the criteria for an organic disease, but are of a medical concern. Kroenke and
Mangelsdorff (1989) found that only 1 out of 10 of the most commonly seen complaints made in
primary care was determined to have a medical etiology 1 year after the initial complaint. In this
very large group of patients with vague symptoms, there is a huge opportunity for preventive
behavioral health intervention programs. Although user-friendly screening instruments can help
providers tease out behavioral health-care issues, the development of generic behavioral health
patient education materials designed to improve coping and stress management skills can be tre-
mendously helpful. Primary care is the ideal setting for teaching patients problem-solving skills, as
these skills have wide applicability to the many psychosocial factors that drive care (Mynors-Wallace,
Gath, Lloyd-Thomas, & Tomlinson, 1995). For all of the potential promise, there still appears to be
a significant mismatch between what primary care patients are seeking and what primary care
clinicians are prepared to provide (Sobel, 1995). This mismatch results in lower levels of patient
and provider satisfaction as well as poorer health and behavioral health outcomes.
Primary Care Is Fast-Paced and Immediate

Diagnostic and treatment interventions, by necessity, are brief in primary care. Providers work in
10- and 15-minute units of time. Although visits with depressed patients are slightly longer than
visits with nondepressed patients, they are far shorter than patient visits with psychiatrists (Olfson
& Klerman, 1993). Consultations with colleagues and other medical team members are brief and
occur at the time of need. They may be initiated by a knock on the door of a treatment room where
a colleague is working with a patient or spontaneously in a “curbside consultation” between provid-
ers as they move between patients. The knock-on-the-door rule is a significant cultural difference
between primary and many mental health-care settings. Primary care providers often marvel
at how long behavioral health providers take to accomplish a treatment session. They view the 50-
minute visit as a luxury they can ill afford in their busy daily practices. Generally, behavioral health
interventions requiring more than 2–3 minutes cannot be accomplished during typical medical
encounters. In mental health terms, primary care providers operate using a “15-minute hour.”
Primary Care Is “Primary”

Regardless of the presenting problem or the levels of care involved, patients begin and end episodes
of care with their primary care teams. Often the longest health-care relationship a patient will have
is with his or her family doctor. In many managed health-care systems, primary care physicians act
as care managers or “gatekeepers.” They are responsible for coordinating referrals to various
subspecialties, including mental health and chemical dependency services. In most instances, it is
the primary care provider who is the first and the last professional involved with a patient during a
period of compromised psychological functioning. Therefore, primary care providers are in a key
position to detect escalating symptoms of psychological distress as well as to support long-term
treatment gains associated with effective, ancillary psychological and psychiatric treatments.
This feature of the primary care setting is critical to achieving improved clinical and cost out-
comes with behavioral health conditions. For example, nearly 70% of depressed primary care
patients report at least one previous episode of depression (Robinson et al., 1995). It is in primary
care, not specialty care, where recurrent psychological conditions, like depression, can be managed
proactively on a long-term basis. Primary care is an ideal setting for applying risk-based protocols
and other population-management strategies to recurrent or chronic medical and psychological
health conditions. This “hub of the wheel” nature of primary medicine also has a dark side. When
treatment protocols fail in mental health or chemical dependency treatment settings, the patient
ends up returning to the primary care provider, often in a state of greater disrepair than before the
initial referral was generated. Primary care providers tend to view mental health and chemical
dependency services with great skepticism. They experience these services as a “black box” in which
communication with the primary care provider is nonexistent and treatment practices are both
mysterious and ineffective. The negative images of mental health and chemical dependency provid-
ers that are commonly held by primary care providers are in large part due to the apparent failure
of these specialists to appreciate the central role of the primary care provider as a care coordinator.
Population-Based Care
Population-based care is grounded in public health concepts that may be unfamiliar to many
behavioral health providers. The population-based care approach is designed to help the health-
care system achieve satisfactory levels of basic preventive care, accessibility to acute care, and
effective chronic disease management. This approach uses public health and epidemiological prin-
ciples to describe a population, analyze care for problems of highest priority, and design and
modify services to deliver that care and monitor the results. This approach has been applied to
community-oriented primary care, as well as to age-group and chronic-disease-group populations.
There are two basic principles of population-based care that are relevant to the migration of ESTs
into primary care. First, population care is effective only to the extent that basic clinical services can
be accessed by a large percentage of the medical population. This generally involves the philosophy
of providing limited services to many members of the population, instead of providing intensive
services to few members. Second, population-based care interventions work best when they are
designed to address the preferences of consumers. When consumer acceptance of interventions is
high, consumers are more likely to seek the service and to follow the required steps of an acute or
preventive intervention.
Table 2.1 lists five steps involved in the development of population-based care programs. These
steps can be applied to behavioral health problems as well as medical problems. In the last section
of this chapter, these steps are woven into a functional template for developing population-specific,
TABLE 2.1 Five Steps to Development of Population-Based Primary Care Programs

1. Choose a common condition that is amenable to a systems approach to care.
2. Identify a method for identifying patients in the primary care practice who have the selected condition.
3. Choose measurable outcomes that reflect best evidence-based medical or behavioral health practice for
that condition.
4. Form a high-performance team to implement a system of care that improves outcomes.
5. Measure outcomes regularly and make changes as needed to improve outcomes.
evidence-based programs for primary care. These steps have proven useful in developing “vertical”
integration programs that yield strong clinical, cost, and satisfaction outcomes (Katon et al., 1995,
1996; Von Korff et al., 1998).
Population-based care methods have provided structure for the development of most preventive
medical programs. Many preventive medical problems involve risk-identification methods and
behavioral counseling (U.S. Preventive Services Task Force, 1989). In fact, most preventive inter-
ventions can be classified as counseling interventions. These include educational programs aimed
at risk factor modification as well as motivational interviewing strategies (e.g., tobacco use or
unsafe sexual practices) (U.S. Preventive Services Task Force, 1996). Preventive behavioral activities
occur in all areas of primary care medicine, including internal medicine, family medicine,
pediatrics, and obstetrics and gynecology.
Taplin et al. (1998) have demonstrated that a population-based care program involving health-
risk-factor screening and modification activities can be both feasible and practical when applied to
an individual primary care physician’s practice. This group of primary care researchers used a team
model of care in a primary care practice to improve the proportion of eligible patients who
achieved recommended levels of colon cancer screening and breast mammography. Behavioral
health providers who plan to become primary-care team members need to anticipate possible
applications of the population-based care model to prevent behavioral health problems and to treat
intermittent, recurrent, and chronic behavioral disorders.
Evidence-Based Medicine
Among the behavioral health community, evidence-based medicine often is misconstrued as the
process of using empirically validated treatments that are supported by clinical practice guidelines.
This conception belies the true complexity of the evidence-based medicine model. Like population-
based care, evidence-based medicine is rooted in clinical epidemiological and public health
concepts. It involves the conscientious, explicit, and judicial application of current best evidence in
making decisions about patient care. The practice of evidence-based care requires integration of
clinical expertise with the best available external clinical evidence from systematic research. Within
the context of everyday patient care, the provider that practices evidence-based medicine seeks to
balance the factors of research evidence, clinical expertise, and patient preferences in providing care
to the individual patient (Sackett et al., 1996). The steps in the clinical practice of evidence-based
medicine include (1) selecting specific clinical questions from the patient’s problem(s); (2) search-
ing the literature or databases for relevant clinical information; (3) appraising the evidence for
validity and usefulness to the patient and provider practice, and (4) implementing useful findings
in everyday practice (Rosenberg & Donald, 1995).
In addition to assisting with the care of the individual patient, evidence-based medicine has the
potential to inform and guide clinical decision-making concerning cost-effectiveness analyses and
health policy development. Geyman (1998) suggests that evidence-based medicine consists of five
components—each with an associated product. These component-product pairs include clinical
epidemiological studies that produce practice guidelines, meta-analyses that produce care path-
ways, clinical trials that produce performance measures, cost-effectiveness analyses that produce
process-based products, and decision analyses that produce outcome-based products.
A major product of evidence-based medicine is the development of a practice guide suggesting a
quality hierarchy for guideline development (Eddy, 1996a; Eddy, Hasselblad, & Shachter, 1992).
Guidelines have proliferated in recent years, as specialty organizations and governmental agencies
have attempted to apply evidence-based medicine to conditions of concern. Unfortunately, the
quality and value of early guidelines was variable, and a guideline is only as strong as the rigor of
the scientific process involved in its development. A strong guideline is based on empirically
validated clinical outcomes and patient preferences. Eddy (1996a; Eddy et al., 1992) suggested a
quality hierarchy for guideline development that moved from the most basic level of global subjec-
tive judgment to the level of having an evidence base. The highest level in Eddy’s quality hierarchy
is the research-based practice guideline that is sensitive to patient preference. The Agency for
Health Care Policy and Research (AHCPR) has created 19 practice guidelines and has established a
group of evidence-based practice centers around the country to develop guidelines on a contrac-
tual basis (Practice Trends, 1997). AHCPR also created a national guideline clearinghouse on the
Internet.
Use of evidence-based principles in primary care medicine has developed into an everyday
reality for group and solo primary care providers, as they have begun to use Internet services on a
daily basis. There are two major types of electronic databases used by physicians. One is
bibliographic (e.g., MEDLINE), which retrieves relevant citations. The other provides direct access
to evidence concerning specific clinical topics (e.g., the Cochrane Database of Systematic Reviews).
Primary care providers may be employing evidence-based treatments in as many as 80% of their
interventions (Ellis, Mulligan, Rowe, & Sackett, 1995; Gill et al., 1996). In one study, 53% of the
treatments were supported by data from randomized clinical trials, while 29% were supported by
convincing nonexperimental evidence (Gill et al., 1996).
Evidence-based medicine and population-based care methods empower providers to address the
difficult issues related to resource allocation in a health-care system where needs often exceed
resources. It should be noted that the growing emphasis on ESTs in the behavioral health industry
has developed in relative isolation from the principles guiding evidence-based medicine. Evidence-
based medicine is far more complicated than simply looking at the results of clinical trials and
implementing a procedure based upon the empirical results alone. When implemented properly,
this approach to medicine integrates cost considerations, risk-benefit to the consumer, existing
variability in costs and outcomes, and strength of empirical evidence, as well as consumer prefer-
ences. Eddy offered the following 10 principles to guide the development of evidence-based models
(Eddy, 1996b, pp. 252–265). Behavioral health providers need to familiarize themselves with these
principles as they will wrestle an even larger monster of high needs and low resources when they
work in primary care.
1. Consider financial costs of interventions.

2. Set priorities.
3. Understand that it is not feasible to provide every treatment that might have some benefit.
4. Know that the objective of health care is to maximize the health of the population served
with available resources.
5. The priority of a treatment should not depend on whether a particular individual is our
personal patient.
6. Priority-setting relies on estimates of benefits, harms, and costs.
7. Empirical evidence takes priority in assessing benefits, harms, and costs.
8. A treatment must meet three criteria before being promoted for use:
a. Compared with no treatment, treatment is effective in improving health outcomes.
b. Compared with no treatment, benefits outweigh harms of outcomes.
c. Compared with next best alternative treatment, the treatment is a good use of resources
for the population served (principle 5).
9. Patient preferences should be sought in making judgments of benefits, harms, and costs of
a treatment.
10. In determining whether a treatment satisfies principle 8, the burden of proof is on those
promoting its use.
These principles may seem obvious and unassailable, but there are many examples where they
have not been followed in both medicine and behavioral health. Electronic fetal monitoring, for
example, became widely applied with major impacts on perinatal care without satisfactory demon-
stration of criteria stated in principle 8 above. Behavioral health providers in primary care need to
understand this larger set of decision rules when attempting to implement EST programs. Up to the
present, there are few examples of EST programs being integrated within a system of primary care.
This is due to the lack of onsite behavioral health services in most primary care clinics and to the
rigor of the evidence-based model. The behavioral health provider who works in primary care is
challenged to use the most relevant and valid data, as well as patient preferences, to create EST
programs within the decision rule constraints imposed by evidence-based medicine.
The Primary Behavioral Health (PBH) Model

Several recent publications have described a Primary Behavioral Health Model (Strosahl, 1994,
1996a, 1996b, 1997, 1998; Strosahl, Baker, Braddick, Stuart, & Handley, 1997). This model involves
managing the psychosocial aspects of chronic and acute diseases (i.e., behavioral medicine) and
addressing lifestyle and health-risk issues (i.e., health psychology) through brief consultative
interventions and temporary comanagement of certain behavioral health conditions. There is an
emphasis on early identification and treatment, as well as long-term prevention and support of
healthy lifestyles. Primary behavioral health services are delivered with a goal of increasing the
effectiveness of primary care providers in addressing the behavioral health needs of patients. Behav-
ioral health providers see patients in exam rooms or in offices nested in the primary care clinic.
Behavioral health providers do not take charge of the patient’s care, as would be the case in a spe-
cialty mental health approach. The goal is to manage the patient within the structure of the primary
care team, with the behavioral health provider functioning as an integral member of this team.
Patients see behavioral health as a primary care service. Their care feels seamless. When a patient
fails to respond to primary behavioral health care, or obviously needs specialized treatment, the
patient is referred to a specialty mental health service (Strosahl, 1994). The Primary Behavioral
Health Model also relieves patient concerns about receiving a “mental health” service. Conse-
quently, many populations that have historically been reluctant to receive specialty mental health
services (i.e., the elderly, male adults, ethnic and cultural minorities) accept care more readily from
a behavioral health provider.
There are two distinct but complementary approaches to providing integrated behavioral health
care. These have been described as horizontal and vertical models of integration (Strosahl, 1997).
Horizontal integration is the most basic form of integrative care because almost any behavioral
health problem can benefit from a well-organized general behavioral health service.
Horizontal Integration
Horizontal integration programs are designed to serve all comers. In this model, the goal is to
deliver a large volume of brief psychosocial services that systematically improve the health of the
entire primary care population. This model reflects the population-based care model used for
primary medical services. Only small numbers of patients who require specialists are referred to
specialty treatment centers and hospitals. This model is described extensively elsewhere (Strosahl,
1997). In the approach, the goal is to raise the skill level of primary care team members in treating
behavioral health problems. Over time, primary care providers learn to handle routine problems
more effectively in the context of 10-minute medical visits. Primary care providers learn quickly in
a model that involves both consultation and the comanagement of cases. In this model, the behav-
ioral health of the primary care population benefits from improvements in care delivered by
primary care providers. As the primary behavioral health consultant “works him- or herself ” out of
the job of seeing less complex patients, more effort can be put into development of vertical
behavioral health programs. In this sense, the horizontal integration provides a framework from
which EST programs can be implemented successfully.
Vertical Integration
Vertical integration involves providing treatment according to a specific protocol to a defined
subpopulation, for example, depressed primary care patients. Vertical integration programs are
developed to serve highly prominent populations. Primary care populations may be prominent
because they are prevalent, as is the case with depressed patients, or because they are high-profile
patients, as may be the case with chronic-pain patients. Common vertical integration targets are
high prevalence conditions, such as depression, panic disorder, or high-impact conditions, such as
somatization and chronic pain. Vertical integration programs may be linked to clinical treatment
pathways or practice guidelines. Vertical programs typically have both acute- and preventive-
treatment foci. This allows the program to accommodate patients needing different levels of care
and to prevent relapse. Successful vertical integration programs are developed through application
of the principles of population-based and evidence-based medicine.
Relationship Between Horizontal and Vertical Integration Strategies

In most systems, the majority of primary care patients with behavioral health problems obtain
benefit from primary care behavioral health services. These brief services focus on personal
problem-solving, targeted skill development, and effective use of coping skills to respond to current
psychosocial stresses. Patients with more complex problems benefit from more aggressive treat-
ment, and these can be provided cost effectively in clinical pathways and in accordance with guide-
lines established by the employing organization or an independent body. To be fully integrated, a
system should have a combination of targeted clinical pathways that address the needs of high
frequency or high-impact subpopulations and a highly accessible horizontal integration service that
serves as an easy access point for other patients.
Applying Vertical Integration Strategies to Behavioral Health Conditions in Primary Care

As discussed earlier, vertical integration programs are designed for high-frequency and high-impact
behavioral health conditions. These programs need to include highly condensed, evidence-based
interventions tailored to fit the fast pace of primary care. Temporary comanagement strategies with
one or more medical team members often are key components of vertical programs. Although
more behavioral health services are provided in vertical integration programs, the focus continues
to be on patient education, self-management skills, medication adherence, and creation of a context
where primary care team members reinforce each other’s treatments. An example of an EST-based
vertical integration program is the Integrated Care Program (Robinson, 1996; Robinson et al.,
1996). In this program, a primary care provider and behavioral health consultant work together in
a structured program that combines cognitive behavioral and pharmacotherapy treatments for
patients with major depression or depressive symptoms secondary to life stresses and transitions
(Robinson, 1996; Robinson et al., 1996). Compared with the usual care available in general
medicine settings, randomized clinical trials have shown that the Integrated Care Program
produced superior clinical outcomes, better medication adherence, increased use of coping strate-
gies by patients, and significantly increased patient and provider satisfaction (Katon et al., 1996).
Interestingly, the remission rates (approximately 70%) obtained in these studies compare very
favorably with those reported in specialty field trials examining the effects of cognitive behavioral
and medication treatments for depression (Elkin et al., 1989). This occurred even though the
Integrated Care Program required only 3–4 total hours of behavioral health provider service. This is
about a quarter of the treatment intensity observed in most clinical trials comparing treatments
for depression.
Concepts, Problems, and Adaptation Targets for Redesigning ESTs for Primary Care
Given the radical differences in philosophies of care and patient populations, evidence-based
mental health treatments are unlikely to transfer well to the primary care environment in their
current form. Typically, they are too time-intensive, they cannot accommodate large patient flow,
they lack a central patient-education or home-based, self-management focus, and they may not
address the service preferences of primary care patients. Clinician researchers have attempted to
deliver state-of-the-art mental health treatments for depression in a primary care setting without
adaptation. Schulberg et al. (1996) have evaluated the effectiveness and feasibility of providing
interpersonal therapy to depressed patients in a primary care setting. His team carefully followed a
protocol determined to be effective in the mental-health-clinic setting. This study compared
patients receiving interpersonal psychotherapy or pharmacotherapy with patients receiving usual
medical care. Among treatment completers, approximately 70% of patients participating in the full
pharmacotherapy or psycho-therapy protocol were judged as recovered at 8 months while only
20% of the usual care patients recovered. Unfortunately, only 33% of the pharmacotherapy and
42% of the psychotherapy patients completed active and continuation treatment phases, respec-
tively. Less time-intensive versions of ESTs, such as brief interpersonal therapy, are required to
retain and treat the high number of primary care patients who present for care. Careful attention to
nine primary care program goals can help the behavioral scientist adjust ESTs for successful pri-
mary care implementation. Table 2.2 summarizes these goals, defines characteristics of ESTs that
deserve evaluation, and suggests desired adaptations in ESTs for the primary care setting.
Embrace the Primary Care Service Philosophy

Most ESTs focus on provision of individual therapy in a specialist-based model of care. The orien-
tation in mental health has always been to provide more intensive services to a smaller percentage
of patients. In contrast, the philosophy of primary care is to provide much more abbreviated
services to a much larger percentage of eligible patients. The mission is to improve the health of the
community, not just the health of a few individuals in the community. This means that ESTs being
reformulated for primary care must address the vast differences between programs designed for
3–5% of the population and those designed for 20–30%. In primary care, the mission is to serve the
larger number of clients who do seek care for psychological problems, as well as those who do not
seek care.
Expand the Population to Be Served

Most evidence-based mental health treatments are tested in clinical trials where subjects are
required to meet stringent criteria for a specific mental disorder. Patients with co-morbid mental
disorders, with subthreshold symptom complaints, or with problem drinking or drug abuse
patterns are typically excluded. In primary care, patients will present with a much wider range of
symptoms and co-occurring disorders or problematic behaviors, and they are the rule rather than
the exception. In fact, patients with subthreshold symptoms are more common than patients with
full-blown syndromes. For every patient who meets the criteria for major depression, there will be
at least one to two primary care patients with subthreshold depressive symptoms (Katon et al., 1995
1996). Interestingly, losses in role functioning for patients with milder forms of depression may be
TABLE 2.2 EST Characteristics, Primary Care Goals, EST Adaptation Targets
Primary Care Goals ESTs in Mental Health Primary Care ESTs
1. Embrace the primary care Client-focused Population focused
service philosophy 3–5% penetration 20–30% penetration
2. Expand the population to be Diagnostic syndromes only in All symptom levels treated within
served homogenous protocol; protocol; range of interventions available
subthreshold conditions
excluded
3. Plan for population diversity More educated; more females; Less educated; more males; worse health;
better health; less ethnic and more seniors; more ethnic and racial
racial diversity; co-occurring diversity; less literacy; more
disorders excluded in clinical co-occurring mental, chemical and
trials; separate treatment of medical disorders; high prevalence of
mental health and chemical drug and alcohol problems by
dependency disorders adolescents, adults, and seniors
4. Use a patient-centered care Patients expect longer Patients expect very brief encounters that
approach sessions and more sessions focus on advice and action
over time
5. Deliver services in multiple Predominantly one to one, Multiple service formats include
formats couple, group, family therapy consultation; temporary comanagement;
in solo provider model flexible delivery models such as 1:1,
telephone, group care clinic, classes
6. Reduce treatment length and Eight to 20 1-hour treatment Four to six 30-minute contacts
intensity sessions
7. Convert to a patient Specialist psychotherapy Consultation and technical support to
education model delivered in sequentially based patient; patient education and home
protocol based self-management strategies taught
in freestanding modules
8. Adopt a relapse prevention Acute treatment focus; passive Risk monitoring and relapse prevention
focus relapse prevention focus; an integral part of longer term
patient to return to therapy if management protocol; risk monitoring
condition worsens is carried out by all medical team
members
9. Build a team-based Solo practitioner focus; Protocol designed to be delivered or
intervention minimal, if any, relationship supported by any member of the
to patient’s health-care team health-care team; team visits
choreographed to create a seamless,
consistent model of care
equal to those associated with major depression. Patients with subthreshold depressive symptoms
have been found to have worse physical, social, and role functioning; worse perceived current
health; and greater bodily pain than patients who have no behavioral health conditions (Wells et al.,
1989). The primary care setting holds tremendous potential for addressing milder forms of com-
mon behavioral health conditions, thereby preventing the onset of more severe psychological prob-
lems. Delivery of components of EST programs for patients with subthreshold symptoms (e.g.,
patient education materials provided by the primary care provider) may enhance the realization of a
medical cost offset associated with delivery of integrated behavioral health services (Von Korff et al.,
1998). Behavioral health program designers need to redesign programs so that treatment protocols
can be tailored to patients presenting with varying levels of symptoms and impairment in activities
of daily living.
Plan for Population Diversity

In terms of demographic characteristics, primary care patients are a diverse group who differ from
the typical group of subjects included in an EST research study. For example, depressed primary
care patients are likely to be older and less educated than depressed patients who go to mental
health specialists (Wells et al., 1989). They are also more likely to be married and of diverse ethnic
backgrounds. There is a much higher percentage of monolingual patients and, in general, the
education and literacy levels of primary care populations tend to be somewhat lower.
Medical co-morbidity is much more common in primary care than in mental health settings.
Primary care patients with behavioral disorders often have multiple medical problems. The effects
of medical conditions and psychological disorders, such as depression, on patient functioning
appeared to be additive (Wells et al., 1989). For example, a patient with advanced coronary artery
disease and depression may have twice the loss in social functioning compared with that associated
with either condition alone. Patients with numerous medical conditions need to be treated along-
side the multitude of other primary care patients with depressive symptoms.
The availability of EST programs for patients with co-occurring mental and chemical depen-
dency problems needs to be improved. Most existing EST protocols are developed with patients
who do not suffer from the mood, thought, and function-altering effects of ongoing substance
abuse. Similar to the mental health population, most patients with chemical dependency issues are
managed entirely within the primary care milieu, according to the Primary Behavioral Health Care
Model (Strosahl, 1997). Many decline referral to chemical dependency treatment programs. EST
programs need to anticipate and address the service needs of these more complicated patients.
Sciacca and Thompson (1996) outline an example of the development of a dual or multiple disorder
program that integrates diverse systems and provides comprehensive services within each of the
programs within each delivery system. These types of programs can be cost-effective, can correct
the issues of incompatible treatment interventions, and can end the dilemma of gaps in service sys-
tems and limited referral resources. The primary care setting is ideal for recasting chemical depen-
dency as both a behavioral and physical health problem. Behavioral health consultants, along with
primary care nurses, can take the lead roles in improving recognition of alcohol, tobacco, and other
drug (ATOD) abuse problems in the primary care setting because this setting is fertile for cross-
training among professionals, early detection, and ongoing relapse prevention efforts.
Use a Patient-Centered Care Approach

Most ESTs are designed for mental health clients, and their experiences in the mental health system
have conditioned them to expect hour-long treatments that continue for months and, even years.
Nevertheless, a significant percentage of mental health clients fail to adhere to typical EST protocols
requiring only 10 to 20 sessions. When patients with behavioral health conditions present to the
primary care setting, they expect brief treatments that provide them with education and self-man-
agement skills (e.g., medication information, problem-solving advice, educational pamphlets, etc.).
Transferring EST protocols without significantly adjusting the service delivery model will result in
significant patient adherence problems. Schulberg’s (1996) reported excessive dropout rate likely
occurred because the treatment length exceeded what primary care patients are willing to tolerate.
In contrast, a highly condensed patient education approach yielded a treatment completion rate of
over 90% (Katon et al., 1996). Mynors-Wallace et al. (1995) found that 93% of a group of depressed
primary care patients completed treatment when offered a brief problem-solving treatment protocol
for depression. In the same study, 81% of patients assigned to pharmacological treatment completed
the protocol. In both the problem-solving and pharmacological treatment programs, patients were
asked to attend six half-hour treatments over a 12-week period. These studies suggest that primary
care patients tolerate around 3 hours of treatment over a 6-to-12-week period for a condition such
as major depression.
Given the expectation of brief treatment, selection of effective therapeutic modalities and viable
formats is critical. If properly “downsized,” cognitive behavioral treatments for specific disorders
are good candidates for implementation in primary care because they have an educational flavor,
can be easily supported by educational materials, and are used by a significant number of primary
care physicians (Robinson et al., 1995).
Deliver Services in Multiple Formats

Most ESTs are delivered in a 1:1 treatment format and, far less frequently, group or classroom
models. The 1:1 modality is the service delivery model in the overwhelming majority of EST clinical
trials. Unfortunately, the 1:1 modality is the unit of service with the least capacity and, if followed
blindly, will jam the primary care behavioral health provider’s calendar hopelessly in the first few
weeks. This, of course, would result in frustration for both the primary care and behavioral health
providers, and referrals likely would drop off rapidly. In primary care, treatments need to be offered
in multiple formats. For example, a depression treatment program could be delivered in individual
protocols, through telephone contacts, or in a group or classroom protocol. Group and classroom
protocols must use freestanding content modules, to allow patients to enter the treatment program
at any time. Sequentially, organized protocols that rely upon a series of consecutive visits to instill
skills will be unsuccessful in primary care because they do not promote the immediate access
required when patient volume is high. Finally, various medical team colleagues can also be enlisted
to provide services such as making follow-up phone calls or leading groups or classes.
In all respects, flexibility in service delivery is absolutely essential in primary care. Using depres-
sion again as an example, a single prevention visit with the behavioral health consultant might be
sufficient for a patient with mild symptoms, while pharmacological treatment by the primary care
provider might be the choice for a patient who strongly preferred a solo medication treatment.
An older, retired woman might select a 15-minute skill-building session in the morning, whereas
several younger patients would attend a lunch-hour or after-work skill class. A brief behavioral
skill-building booklet could provide the structure for a variety of contact options (Robinson et al.,
1996). Collectively, these strategies maximize penetration into the population of primary care
patients with a specified set of symptom complaints.
Reduce Treatment Length and Intensity

For the most part, evidence-based mental health treatments are developed in the context of an
academically based research program where the probability of funding is greater when results are
positive rather than negative. This paradigm encourages researchers to employ interventions that
include “everything but the kitchen sink.” As a result, evidence-based programs may be much more
time and strategy intensive than is necessary for patient improvement. There is every reason to
believe that the gestalt of primary care, with its emphasis on advice and action, favors the use
of action-oriented, brief interventions. For example, Katon et al. (1996) found that a highly
condensed package of “core” cognitive behavioral depression management skills produced robust
treatment effects. Although there may be some ESTs that simply cannot be distilled into a home-
based, self-management approach, clinical experience in primary care suggests that the majority can
be rendered into this form. For example, anecdotal experience suggests that cognitive behavioral
treatment for panic disorder can be accomplished in three to four 30-minute contacts when
supported by patient education pamphlets, home-based practice, and on-demand telephonic con-
sultation. Less-intensive treatments can be successful in primary care because they are supported
and reinforced by a team of providers. In order to use members of the primary care team to extend
the impact of brief treatments delivered by onsite behavioral health providers, treatment formats
need to be packaged in an educational format and built around structures that support long-term
skill change and increasing levels of patient self-efficacy in self-management. Further, the strategies
need to be concrete, easy to understand, and supportable in the context of a 2-to-3-minute interac-
tion between patient and medical provider.
Convert to a Patient Education Model

The specialty psychotherapy model practiced in mental health and chemical dependency encourages
providers to take a great deal of responsibility for planning and implementing a treatment plan,
often with minimal participation on the client’s part. Although ESTs typically employ some psychoe-
ducational strategies, the requirement for weekly or biweekly therapy sessions clouds the picture as
to who is responsible for making change occur. Is it the therapist, through the accumulating influ-
ence of frequent therapy contacts? Or is the client, by practicing effective coping strategies outside
the therapist’s office, the active change agent? Most mental health providers will give the politically
correct response, that is, the client is the active change agent. At the same time, the same providers
will argue that reductions in session allotments in the era of managed care have harmed the quality
of care. They argue that there is a well-documented “dose-effect” relationship between the number
of sessions of psychotherapy and the amount of clinical gain observed. It seems implicit in these
objections that most therapists believe a frequent presence is needed to guide and structure the pro-
cess of behavior change. In primary care settings, that assumption gives way to what consumers
consistently say they want in health care: to be given the information and skills necessary to manage
their own problems with the minimum amount of assistance from a professional.
Primary care medicine is now characterized by an increasing emphasis on giving patients infor-
mation about their conditions and then educating them in effective self-management skills. This is
an essential feature of contemporary chronic-disease management programs that are proliferating
in health-care settings across the county (Sobel & Ornstein, 1996). In a variety of medical studies,
the patient education, self-management model has been shown to have a pronounced beneficial
effect on health-care process and outcome measures. EST programs in primary care must develop
condensed and informative educational materials, as well as provide an effective structure for the
home-based practice of self-management skills. These education strategies are consistent with con-
sumer preferences and will substitute for frequent visits with the behavioral health provider. In the
modified EST approach, the primary behavioral health provider functions as a consultant and tech-
nical resource for the patient. The responsibility for practicing and assimilating new skills resides
entirely with the patient.
Adopt a Relapse Prevention Focus

Currently, mental health specialists do not place a premium on prevention. Patients are usually
experiencing moderate-to-severe levels of symptom distress and functional impairment when they
access specialty mental health care. Treatment focuses on the reduction of acute symptoms and
discharge occurs when the symptom picture improves. Most patients will leave the termination
session without a written relapse prevention plan and no plan for follow-up “booster” visits. These
patients will reenter the health-care system at greatly increased risk for relapse, without any particular
plan for monitoring their functional and symptom status. In general, relapse prevention strategies
are not widely practiced in mental health and are not required by managed care companies. Not
surprisingly, there is also very little research on the clinical effect of relapse prevention strategies
with recurrent conditions such as depression. In primary care, much of the cost containment and
quality improvement potential with behavioral health conditions is related to the prevention of
recurrences and the use of cost-effective procedures for doing so. For example, a large percentage of
depressed primary care patients are left on antidepressants much longer than is indicated by the
research. Although failing to provide any real prophylactic effect, these expensive medicines directly
affect the pharmacy budget. In effect, an expensive, ineffective treatment is being employed to
prevent recurrence. A far cheaper, effective alternative may be to construct EST programs so that
they include relapse prevention plans, protocols for flagging at-risk patients, and a schedule of
booster contacts with either the behavioral health provider or primary care provider.
The use of EST programs to take advantage of prevention opportunities should be well received
in primary care. After all, the mission in primary care is to keep people healthy and to anticipate and
thwart challenges to wellness. For example, in the study of the Integrated Care Program for Depres-
sion, primary care providers in the study began to formulate relapse prevention plans with 33% of
their usual care patients after receiving brief training to support relapse prevention plans placed in
the charts of the integrated care patients by behavioral health consultants. EST programs that sys-
tematize the use of relapse-prevention strategies might be very popular with primary care providers.
Build a Team-Based Intervention

In contrast to the solo office practice model of specialty mental health, primary care is evolving into
a health-care-team service model. This means that physicians, midlevel providers, and nurses share
a general responsibility for managing the patient’s health care. To be sure, there are specific roles
assigned to each team member based on discipline, experience, and specialized training. However,
the message to the patient is that the team, rather than any one individual, is responsible for pro-
viding quality health care. During a typical medical visit, a patient might have contact with several
members of the team, each performing a particular function. To adapt to this approach, behavioral
health providers need to develop a wide range of “team-performance skills” that optimize the role of
all team members in the patient’s behavioral health care. EST interventions need to be couched in
terms easily understood by the medical provider. Chart notes need to be shared with primary care
providers on a same-day basis with the expectation that medical team members ask about and
support the EST interventions being used with a particular patient. Behavioral health providers can
assist the primary care physician in prescreening the weekly appointment schedule to identify
patients eligible for the program. Visit protocols should be established that choreograph visits with
the primary behavioral health provider and various health-care team members. During each medi-
cal visit, team members need to ask about the patient’s progress toward behavior-change goals.
Finally, there is increasing evidence that primary care providers, with minimal training and
consultative support, can be just as effective as behavioral health providers in managing certain
mental health conditions. For example, Mynors-Wallace et al. (1995) went on to test the delivery of
problem-solving therapy by nurses and demonstrated that primary care nurses and general
physicians were as effective as psychiatrists in implementing and managing problem-solving
interventions and antidepressant therapy with depressed primary care patients. Hunkler et al.
(2000) have tested a nursing-based telephone intervention with depressed primary care patients
that is designed to increase adherence to behaviorally based depression management skills. The
results suggest this model of care produced better adherence, better use of self-management skills,
and improved outcomes. Kent and Gordon (1997) have developed a group care clinic for unstable
hypertensive patients, co-led by a psychologist and an internal medicine physician. This model of
care reduced ambulatory outpatient medical costs, primarily through reductions in emergency
room visits, and increased use of hypertension management strategies by patients. Robinson et al.
(1998) have described a similar group care clinic for frail, elderly primary care patients, co-led by a
family practice physician, psychologist, and nurse. Patients received this program positively, and
findings suggested a change in utilization patterns among participants. A related project involved
identification of elderly high utilizers of medical care and implementation of a nursing-based tele-
phone intervention protocol that focused primarily on behavioral health issues. The results sug-
gested that this intervention was extremely well received by patients and medical providers alike.
The implications of these ground-breaking studies are clear. If one is to produce the volume of
services needed to appreciably affect the behavioral health of the primary care population, EST
protocols will have to be reorganized to permit the delivery of core services by medical personnel.
Second, the primary behavioral health provider will need to assume responsibility for providing
brief, effective training, as well as follow-up consultation to support the intervention activities of
medical providers.
Primary care providers vary in their practice styles, and physician practice style does appear to
be related to patient outcomes (Robbins et al., 1993). Providers seeking to develop behavioral
health programs for specific populations in primary care need to address this variation by including
provisions for variable levels of coparticipation by medically trained colleagues. Some physicians
may prefer to implement EST protocols on their own and may succeed with only minimal curbside
consultations. Other physicians will be reluctant to treat a specific disorder and may avoid an appre-
ciable level of responsibility. However, as is true with all general physicians, they will want to be kept
“in the loop” as the intervention progresses and will remain in charge of the patient’s overall health-
care plan. The behavioral health provider needs to find a way to incorporate these differences, with-
out compromising the integrity of the EST program or assuming the entire burden of care.
In any event, primary behavioral health providers need to develop proficiency in identifying the
unique needs of any particular primary care population and the team-based resources that can be
activated in a cost-effective way. Done properly, EST protocols have the potential to optimize the
impact of primary care team members in addressing the burden of behavioral health problems
in primary care.
Summary
The evolution of health care will most likely involve the integration of behavioral health services
into the routine process of primary care medicine. This will provide the behavioral health industry
with an unprecedented opportunity to reshape the way health is defined. Further, for the first time
since the emergence of behavioral health as an industry, there is a real chance to dramatically
impact the behavioral health of the general population. To achieve this lofty objective, behavioral
health providers will need to adapt their best clinical technology to fit the demands of population
care, evidence-based medicine, and the unique setting characteristics of primary care. The goal of
this chapter has been to provide a framework for the successful translation of evidence-based men-
tal health treatments into evidence-based, primary care behavioral health treatments. It is obvious
that the process of translation will involve goring many a sacred cow, both in form and content.
Behavioral health providers must be pragmatic, rather than paradigmatic, as they approach this
daunting task. Direct experience suggests that thinking “out of the box” is a prerequisite for success
in this endeavor. This mind-set allows us to first develop programs that are likely to work in
primary care, then empirically test whether the results are acceptable. The process of design, test,
and redesign is basic to nearly all models of quality improvement and will serve the primary behav-
ioral health provider well.
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Chapter 3
The Role of the Behavioral Health-Care Specialist
in the Treatment of Depression
in Primary Care Settings
GLENN M. CALLAGHAN AND JENNIFER A. GREGG
Depression is a costly problem both psychologically and financially. This chapter presents an
overview of depression as a biological, psychological, and social phenomenon to be treated in
primary health-care settings. The utility of using an assessment-referral-treatment model makes
use of all members of an interdisciplinary treatment team and focuses on the delivery of psychological
interventions for depression as the primary treatment or adjunctively with medications. A cognitive
behavioral therapy group intervention is described with respect to the necessary components for
conducing the intervention and research evidence supporting its use. The chapter highlights a
financial analysis of using this intervention in primary health-care settings.
Depression as a Biopsychosocial Phenomenon

Clinical depression and depressive disorders, including minor depression and dysthymia, comprise
a set of psychological problems that are costly both emotionally and financially (American Psychiatric
Association, 1994). The prevalence of these depressive disorders has been estimated to range
between 6–20% in the general population (Budman & Butler, 1997; McGue & Christensen, 1997),
and researchers have reported even significantly greater prevalence in primary and mental health-
care settings as compared with community samples (Howland, 1993). For example, dysthymia is
found among 22–36% of persons seeking services in mental health settings and between 5–15% of
those seeking assistance with primary care providers (Sansone & Sansone, 1996).
A contemporary understanding of clinical depression conceptualizes the disorder as being
caused and maintained by biological, psychological, and social factors. While serotonin and norepi-
nepherine continue to be viewed as essential pathways (known as the biological amine hypothesis;
see Buelow, Hebert, & Buelow, 2000), research in the past few decades has emphasized the shared
role of behavioral influences in both the cause and treatment of depression (Charney, Miller,
Licinio, & Salomon, 1995). Comprehensive approaches to the treatment of depression involve the
assessment and treatment of all these factors. However, the medical treatment of psychological
73
problems and the inappropriate or unwarranted prescription of medications (typically selective

serotonin reuptake inhibitors, or SSRIs) can lead to unnecessary costs.
Overall, depressive disorders are associated with poor physical health. Patients suffering from
depression tend to overutilize general and emergency medical services (Howland, 1993; McGue &
Christensen, 1997). For example, Coulehan, Schulberg, Block, Janosky, and Arena (1990) reported
that patients with depressive symptoms received more medical diagnoses (including diabetes and
endrocrine, nutritional, musculoskeletal, and gastrointestinal problems), were prescribed more
medications, and were more likely to have a history of surgical procedures than nondepressed
patients. Depressive symptomology is also found to be higher in patients with connective tissue
problems, gastrointestinal conditions, and cancer (Cavanaugh & Wettstein, 1989).
A key link between physical disorders and depression may be nonadherence to medical recom-
mendations. The relationship between depression and nonadherence to medical treatment has been
shown to be substantial, and depressed patients are up to three times more likely to be nonadherent
to medical recommendations made by their physician than nondepressed patients (DiMatteo,
Lepper, & Croghan, 2000). The issue of nonadherence to treatment recommendations also impacts
depression treatment and is addressed in detail below.
Overall, patients with both physical problems and depressive symptoms tend to report a greater
number of symptoms, receive medical treatment for their medical problems, but typically do not
receive psychological treatment (Wells, Hays, Burnam, Greenfield, & Ware, 1989). Even if one
corrects for the financial costs associated with medical co-morbidity, research indicates that provid-
ing treatments for patients with depressive disorders is more expensive than providing interven-
tions to those without these problems (Simon, Ormel, VonKorff, & Barlow, 1995). Furthermore,
somatic complaints (e.g., headache, fatigue, etc.) described by patients to primary care providers
may be symptoms of depressive disorders, not of medical problems (Coulehan et al., 1990).
Major depression is reported to be one of the most common disorders found in medical practice
(Coulehan et al., 1990). Despite the high prevalence in primary care settings, it is estimated that
only one third of patients with depressive symptoms are properly diagnosed by primary care
physicians (Budman & Butler, 1997; Muñoz, Hollon, McGrath, Rhem, VandenBos, 1994) and as
many as 50% are incorrectly identified as depressed by primary care doctors (Perez-Stable,
Miranda, Muñoz, & Ying, 1990). Even fewer patients who are correctly identified as clinically
depressed receive treatment (Kupfer & Freedman, 1986). The prevalence of depressive disorders,
coupled with the inaccuracy of identification and lack of effective care provision, indicates a clear
need for the behavioral health-care specialist to address the problems of assessment and treatment
of depression in primary care practice settings.
Psychosocial Treatments for Depression

The treatment of depression with psychosocial interventions has been considerably supported by
the empirical literature with regard to efficacy (see for example Robinson, Berman, & Neimeyer,
1990). Typically, however, psychosocial treatments for depression in the primary care setting have
not been considered as a first-line treatment. In a primary care setting, the first and predominant
interaction for patients with depressive symptoms is with their physician, and physicians tend to
employ pharmocotherapy (antidepressant medications) rather than psychosocial interventions
(Attkisson & Zich, 1990). Primary care physicians have numerous classes of drug treatments at
their disposal. Although pharmacological interventions are more often implemented in primary
care, it is unclear whether these interventions are very effective when provided as a stand-alone
treatment by physicians rather than part of a broader, team-based intervention (Lin et al., 1997).
The Role of the Behavioral Health-Care Specialist in the Treatment of Depression • 75
Antidepressant medications have been demonstrated as an effective way to treat symptoms of

depression, but posttreatment follow-up studies demonstrate that they are less efficacious in
maintaining gain than psychosocial interventions (Shea et al., 1992) or interventions combining
pharmacotherapy with psychological treatment (Simons, Murphy, Levine, & Wetzel, 1986; Wells
et al., 2000). Despite the demonstrated long-term superiority of psychological treatment either
alone or in combination with medications, patients with depression or depressive symptoms are
primarily treated with antidepressants (Frank, Kupfer, Wagner, McEachran, & Cornes, 1991;
Katon et al., 2001).
In primary care, other problems with the efficacy of pharmacotherapeutic interventions can be
attributed to physician misdiagnosis, ineffective dosing of medications, insufficient treatment
duration, or other factors related to the delivery of the pharmacological treatment (Katon, Von
Korff, Lin, Bush, & Ormel, 1992). In addition to problems with prescribing medications, there are
other reasons why the treatment of depression in the primary care setting may not be efficacious,
including the limited time physicians have with each patient and their lack of training in effective
assessment of depression.
Physician Collaboration
Given the difficulties in treating depression in primary care, multiple interventions have been
developed and implemented to improve physician collaboration with mental health professionals
in the primary care setting. One approach to improving physician practice with depressed patients
has been to utilize interventions designed to educate physicians about the identification and treat-
ment of depressive disorders. An exemplary study examined the effects of an extensive, 12-month
educational program designed to enhance the primary care physician’s diagnosis and treatment of
depression (Lin et al., 1997). Although this program was more extensive than most interventions
found in managed health-care settings, there were no lasting effects of the education intervention
on changed physician behaviors such as prescribing patterns, medication and dosage selection, and
depression outcomes.
The lack of success with this and earlier versions of education programs designed to improve
physician treatment of depression in primary care has led researchers to shift their focus toward
interventions designed to reorganize service delivery patterns. Katon and colleagues (1995, 2001)
described several waves of interventions designed to target these domains by implementing organi-
zational structure changes to facilitate improved detection and treatment of depression in primary
care. The first wave of these interventions attempted to improve physician detection of depressive
patients by implementing screening procedures in primary care. This wave resulted in more appro-
priate diagnoses of depressed patients, but it did not improve overall outcome (Katon et al., 1995).
The second wave of programs, designed to improve collaboration between primary care physicians
and mental health providers, consisted of interventions that required patients diagnosed with
depression by primary care physicians to be randomly assigned to either an intervention group or a
control group. In the intervention group, a psychiatrist performed a diagnostic interview and
consulted with the physician on treatment selection. This intervention resulted in improved
diagnosing, but it did not appreciably improve depression outcome treatment (Katon et al., 1992).
A third wave of programs, designed to improve depression care in primary care, has targeted
these settings at a broader level through the use of disease management-quality improvement
programs. These programs employ a number of methods, including local expert leaders, perfor-
mance feedback, and workload shifting to enhance primary care providers’ delivery of quality
depression care within the existing setting and providers (e.g., Wells et al., 2000). This type of
setting-level intervention has demonstrated improved outcomes in delivery of treatment and
reduction in depressive symptoms, but no differences in medical visits or costs were discovered
(Wells et al., 2000). There are drawbacks to this type of intervention as well, including the large
amount of resources required to implement such a program and the buy-in required at both the
administrative and physician levels to facilitate physicians performing such roles.
Due to the limited number of improved patient outcomes resulting from either improving
depression screening procedures or structured consultation services with physicians and the
complex buy-in required to implement quality improvement programs at an administrative level,
the final wave of interventions targeted the integration of mental health professionals into the
depression treatment in primary care. In order to fully integrate the mental health professionals,
the treatment course began with the introduction of the mental health professional as part of the
treatment team in the primary care setting. According to Strosahl (1996) the presence of the behav-
ioral health-care specialist in the primary care setting is crucial because it avoids the necessity of the
patient following up on a referral, reduces the stigma of seeing a mental health professional, and
allows for time-efficient interventions for a primary care population who may have difficulties that
do no warrant full-term psychosocial interventions. With the full integration of the mental health
professional in this third wave of intervention, Katon and colleagues (1995) found better physician
adherence to treatment recommendations, and 74% of patients diagnosed with major depression
in the treatment condition showed significant improvement, compared with 44% of those in the
control condition.
Cognitive Behavior Therapy for Depression

Among psychosocial treatments, there are a number of interventions that have been shown to be
efficacious with depression in randomized controlled trials (Robinson et al., 1990). A review of
these treatments is beyond the scope of this chapter. We will focus on one type of psychosocial
intervention, cognitive behavior therapy (CBT; see for example Beck, Rush, Shaw, & Emery, 1979).
CBT is a well-established and efficacious treatment for depression, with research findings indicat-
ing that CBT is an effective treatment for this disorder either in combination with pharmacother-
apy or alone (see for example Antonuccio, Thomas, & Danton, 1997; Evans et al., 1992; Shea et al.,
1992). In primary care settings, efforts have focused on providing both CBT and pharmacotherapy
treatments for patients; both have been found to be somewhat effective (Schulberg, Katon, Simon,
& Rush, 1998) and cost effective (Lave, Frank, Schulberg, & Kamlet, 1998). As discussed above,
other researchers have argued that combined pharmacotherapy treatments or medication interven-
tions alone are not as effective as psychosocial treatments such as CBT alone (Antonuccio, 1995),
and given the dropout rates, side effects, and other issues with medication, psychotherapy is a
better first-line choice for the treatment of depression (Wexler & Cicchetti, 1992).
CBT can be conducted in both individual and group formats, and both modalities are equally
efficacious (e.g., Brown & Lewinsohn, 1984). The principles of this therapy are the same for both.
There are considerable advantages to treating individuals in a group session, including the develop-
ment of social skills for patients, the increased probability of building a social support network,
and learning from other patients’ experiences. Group therapy is also more cost effective and
time efficient for health-care providers and agencies in that one therapist can see more patients
during a 1-to-2-hour time block. For these reasons, we will focus our discussion on the group
treatment approach.
The CBT group treatment developed by Organista and colleagues (1994) provides a structured
treatment approach for using CBT for patient groups with depression. This treatment has been
demonstrated to be empirically efficacious in reducing depression (Miranda & Muñoz, 1994;
Wells et al., 2000). There are several advantages to using a manualized group treatment, such as the
one described here. First, patients are treated in a limited number of sessions (typically 8 to 12).
Second, the manual is given to patients to utilize as a treatment workbook. This allows patients
to continue to work on the topics and strategies discussed in treatment on their own. Third,
the manual offers a structured treatment strategy for therapists to utilize. Fourth, the manual
assists therapists in accountability of treatment effectiveness by integrating ongoing assessment
into the treatment process. This accountability practice is an activity essential in the changing face
of psychological treatment provision in a managed, behavioral health-care industry (e.g.,
Cummings, 1995).
CBT treatments typically focus on three main areas of intervention. The first, or cognitive, area
focuses on strategies to identify dysfunctional thinking, to generate alternatives to ineffective
thought processes, and to have patients document their thoughts so that they might eventually alter
their negative cognitions. The second and third areas typically focus on the behavioral component
of the intervention. Interventions here focus on behaviorally activating the patient and improving
his or her social skills. Focusing on the patients’ level of activity helps them identify and engage in
actions that are more likely to reduce depression and increase their opportunities to receive social
reinforcers. Strategies to improve social interactions focus on teaching patients basic social skills so
that they have the opportunity to engage in positive, rewarding contacts with other people, and to
expand their social support systems.
CBT strategies focus heavily on the importance of requiring patients to complete assignments
outside of the session. These assignments focus on having the patient work on tasks discussed
during therapy sessions and then report back to the therapist or behavioral health-care specialist
the next week. Problems and improvements encountered during the week are discussed and utilized
as opportunities to work on the cognitive and behavioral areas described above.
Behavioral health-care specialists who provide CBT need to receive training in how to deliver an
individual or group therapy protocol for the treatment of depression. The requirements for provid-
ing any psychological intervention vary from state to state but typically involve some licensure and
supervision in a health-care specialty. Under the supervision of a trained doctoral-level clinical
psychologist, other health-care providers can also provide the group CBT treatment (e.g., registered
nurses, master’s level psychotherapists).
Compliance
Whether a behavioral health-care specialist or other primary care support staff conducts the
treatment, it is essential that patient adherence or compliance to the protocol be continually moni-
tored. Compliance with depression treatment, whether pharmacological or psychological in nature,
is viewed as a significant problem (DGP, 1993a, 1993b). Compliance rates have ranged from 4–90%
in individuals diagnosed with mood disorders, depending on the method used for measuring com-
pliance (DGP, 1993a, 1993b). Patient compliance with depression protocols can be challenging for
several reasons.
First, patients may not understand the importance of addressing their problems from a psycho-
logical perspective. It is essential to address this barrier to compliance at the beginning of and
throughout treatment by providing a thorough rationale for the use of a psychosocial intervention
as an adjunct to or separate from pharmacotherapy. Ideally, these would be addressed both by the
primary care physician and the behavioral health-care specialist. Research on patient compliance
indicates that providing patients with information on the cause, symptoms, and natural progres-
sion of depression; options for treatment (including a discussion of the risks and benefits of each
available treatment); and the outcome that can be reasonably anticipated greatly improves patient
adherence to treatment (e.g., Altamura & Mauri, 1985; van Gent & Zwart, 1991).
Second, depressive symptomatology includes cognitive difficulties such as lack of concentration

and problems with memory. These problems can produce noncompliance or nonadherence by
patients simply owing to a lack of ability to comply at that moment, not a lack of motivation to
comply. Provided this is not a neurological problem such as brain injury or dementia, behavioral
health-care specialists can address this difficulty by helping patients develop better strategies to
remember appointments, complete homework assignments, and ask for clarification when
confused. These strategies will likely help the patient in other areas and will lend to the credibility of
the service provider.
Third, the psychomotor retardation that sometimes accompanies depression can appear to be a
lack of motivation. In these cases, it may be appropriate to modify the course of treatment to more
quickly address the need for behavioral activation. Fourth, patients may be having difficulties with
other areas of a multidisciplinary intervention, particularly medication. For example, patients may
be experiencing side effects or may be not be dosed adequately. Research has shown that over 40%
of patients prescribed antidepressant medication stop taking their medication after 3 months
(Katon, 1995) despite recommendations for continuing medications 6–12 months after the resolu-
tion of the episode of major depression. This is a concern that should be anticipated and addressed,
as it may be predictive of patients prematurely discontinuing a psychosocial intervention due to
dissatisfaction with treatment.
Primary Prevention and Long-Term Management of Depression

Primary prevention of depression is an area that has received increased attention in the era of
managed health-care organizations and population-based care (see chapter 2). Although this is an
area that largely has not produced consistent outcomes, some studies have begun to illustrate that
when prevention interventions target low-income, at-risk populations in a primary care setting,
significant decreases in prevalence of depressive symptoms can be observed and maintained (e.g.,
Muñoz et al., 1995). These studies have utilized a cognitive-behavioral group treatment for depres-
sion discussed in more detail below.
Unlike primary prevention, there has been considerable attention paid to the long-term manage-
ment and secondary prevention of depressive symptomology. Until recently, long-term medication
use has been the most validated and utilized approach to prophylaxis in depression, with the
best results obtained when patients are maintained on the dose and type of medication effecting
clinical change in the acute phase of treatment (Kupfer et al., 1992). Within the past decade,
researchers have begun examining the effects of psychosocial interventions with regard to the long-
term management of depression, illustrating that continuation of psychosocial treatment in mainte-
nance form can also significantly reduce recurrence of depression (e.g., Frank et al., 1990, 1991;
Kupfer et al., 1992). CBT for depression (see description below), administered during depressive
episodes, appears to be effective in reducing rates of relapse and recurrence of depressive symptoms
(Simons et al., 1986; Wells et al., 2000). Additionally, studies comparing the long-term outcome of
CBT-treated patients with medication-treated patients who were then withdrawn from medication
have consistently found fewer relapses or need for further treatment in the CBT group (Blackburn,
Eunson, & Bishop, 1986; Evans et al., 1992; Shea et al., 1992). Some researchers argue that these
findings suggest that CBT’s effectiveness in reducing depressive symptoms and risk for relapse lies in
its ability to teach patients social skills and develop changes in their thinking (Teasdale et al., 2000).
Assessment of Depression
The need to assess for depressive symptoms in primary care has been documented above. That
physicians are not especially equipped to accurately assess depressive symptomatology has also
been addressed. In this section we discuss one basic assessment tool that can be used in primary
care and offer a model for an assessment and referral process for the coordinated-care treatment
of depression.
Assessment of Depressive Symptoms

There are numerous assessment tools for identifying and tracking depressive symptoms. Some of
these are used in the context of making a formal research diagnosis, while others are tailored to
different theoretical models for depression. The Beck Depression Inventory and Beck Depression
Inventory-2 (BDI-2; Beck, Steer, & Brown, 1996; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961)
are commonly used, self-report instruments that measure the cognitive, affective, behavioral, and
vegetative symptoms of depression (Beck et al., 1961, 1996). The assessment device consists of 21
items, each rated from 0 to 3, that assess the intensity of depressive symptoms experienced during
the previous 2 weeks. Scores on the BDI range from 0 to 63, with higher scores indicating greater
levels of depression. The BDI-2 typically takes less than 5 minutes to complete and 1 minute to
score and interpret.
Research findings support the use of the BDI to screen for and diagnose depressive disorders by
physicians in primary care settings (Zich, Atkisson, & Greenfield, 1990). There is evidence that
using a depression screen is viewed favorably by primary care physicians, and that the use of these
devices assists physicians in diagnosing and treating depression (Rucker, Frye, & Cygan, 1986).
Although the BDI is not a structured clinical assessment device, it does provide a reliable assess-
ment of the level of depressive symptomatology.
Scores on the BDI indicating depression vary, depending on the level of severity of depression as
well as the purposes for which the assessment device is used. Scores of 16 and above on the BDI
indicate that the patient is currently experiencing symptoms of depression (Beck, Steer, & Garbin,
1988). This cut-score has been established in the literature as being sensitive to detecting symptoms
of depression without falsely identifying as depressed those individuals who report some sadness,
but who are not experiencing clinical depression (Zich et al., 1990). Those individuals scoring
above 30 (in the severe level range; Beck et al., 1988) tend to be severely depressed, often suicidal,
and may need more intense care than is afforded in a group treatment approach. The research liter-
ature is unclear which type of treatment most benefits individuals with severe levels of depression,
but it appears that they do not benefit from short-term psychotherapy interventions.
Physicians and their office administrative staffs, behavioral health-care specialists, and other
members of a multidisciplinary care team can all provide and score a BDI when provided as a
paper-and-pencil assessment device.
Model of Multistep Assessment and Referral Process

As described earlier, assessment is important, but not sufficient, to improve outcomes for depres-
sive patients (e.g., Katon et al., 1995). We offer a model for collaborative care that has been devel-
oped based on suggestions from the empirical literature (Callaghan, Gregg, & O’Donohue, 2000).
In an established relationship with primary care physicians we propose a three-step model of
assessment, referral, and treatment.
In the first step, we suggest the assessment of any patient who has demonstrated an affective
problem (e.g., evidences sad or depressed mood, reports decreased pleasure in activities) or self-
reports difficulties with sad mood. The first phase of the assessment process begins with having
physicians’ office staff members administer and score BDIs for these patients. If the patient scores
above 10 on the BDI, the staff then places the copy of the BDI at the front of the patient’s chart
flagged with a colored note to alert the physician.
In phase two of the assessment process, the physician then administers a brief screen to each of
these patients (see Figure 3.1). This screen prevents those individuals from receiving a treatment
for depression when it is not the correct diagnostic match for the patient, or it is not warranted.
BRIEF MOOD ASSESSMENT

PHYSICIAN REFERRAL FLOW CHART FOR DEPRESSION GROUP
© Callaghan 2001
9 < BDI < 40 – USE CHART:
BDI ≥ 10 USE FLOW REFERRAL FLOW CHART FOR DECISION
BDI > 40 DO NOT REFER
BDI ≤ 9 DO NOT REFER
1. Have you been feeling SAD, DOWN, or like you are functioning at LESS THEN YOUR OPTIMAL
LEVEL for more than 2 weeks?
if YES if NO
continue Do NOT
Refer STOP HERE
2. In the past several months, have there been several days at a time where you felt more ELATED (or
really felt excited) even more than your normal feelings of being happy or excited or when you
DIDN'T NEED TO SLEEP more than a few hours a night (for several nights in a row) but still had a
LOT OF ENERGY the next day?
if NO if YES
continue Do NOT
Refer STOP HERE
(BAD?)
3. Have you been feeling sad, down, or at a suboptimal level for MORE THAN 6 MONTHS?
if NO if YES if YES
continue BDI > 16 BDI > 10
REFER OPINION
4. Have you experienced any PERSONAL LOSS or DRAMATIC CHANGE in your life in the last six
months that has left you feeling sad, depressed, or at a suboptimal level?
if YES if NO if NO
continue BDI > 16 BDI > 10
REFER OPINION
5. Were you feeling like you were functioning at near your optimal level BEFORE THIS
PERSONAL LOSS OR DRAMATIC CHANGE?
if YES if NO if NO
Do NOT BDI > 16 BDI > 10
Refer REFER OPINION
Fig. 3.1 Brief mood assessment physician referrral flow chart.

The physician-administered device includes questions to be asked by the physician about the quality
of the patient’s current distress. The screen will disqualify for referral to the CBT treatment all
patients currently experiencing distress due to a recent interpersonal loss (adjustment disorder with
depressed mood or bereavement) as well as those individuals who experience manic symptoms con-
sistent with a diagnosis of bipolar affective disorder. Symptoms of depression in individuals with an
adjustment disorder or who are grieving the loss of a loved one typically spontaneously remit within
several months. Patients with bipolar affective disorder experience a variety of symptoms and prob-
lem behaviors not covered in a CBT treatment of depression. This screen is not designed to require
the physician to make a formal diagnosis of major depressive disorder. Instead, it is designed to be
sure that as many appropriate patients as possible are referred to a CBT group treatment.
Provided the patient meets the criteria for referral to the CBT group, the physician then informs
the administrative staff member who, in turn, contacts the behavioral health-care specialist and
refers the patient to the group. The behavioral care specialist then contacts the patient within 1 to
2 days to set the appointment to begin the group therapy. The group treatment can be conducted
weekly for 90 minutes per session for 8 weeks. Our model requires several groups with rotating
admission sessions for new members so that these newly referred patients need not wait longer than
1 week to begin treatment.
A Brief Economic Analysis of Depression

Not only do depressive disorders take an emotional toll on more than 11 million Americans each
year (Budman & Butler, 1997), but studies indicate that depression has a tremendous financial
impact. Estimated costs to the nation range from $2.7 billion to $5.6 billion annually in service
provision (Rost, Zhang, Fortney, Smith, & Smith, 1998). These costs increase to as much as
$30.4 billion to $44 billion annually, based on larger indices including work absenteeism, decreased
productivity, treatment, and other factors (Antonuccio et al., 1997; Keller, 1994).
Much attention has been paid in the past decade to the cost of treating depression and the
demonstration of cost-offset in the area of interventions for depression. Although some of the argu-
ments for different interventions, particularly behavioral versus pharmacological, can be viewed as
rhetoric, some recent empirical analyses have emerged. The difficulty in examining this literature lies
with the equivocal nature of the data. Although some studies show demonstrable cost-offset and sav-
ings for depression (Dwight-Johnson, Unutzer, Sherbourne, Tang, & Wells, 2000), others indicate
that this cannot be shown as clearly (Schulberg, Pilkonis, & Houck, 1998). One of the reasons for this
lack of evidence for cost savings is the different types of interventions employed, the cost of these, the
involvement of medications (particularly brand name SSRIs), and the time or intensity of the inter-
vention (see for example, Antonuccio et al., 1997; Von Korff et al., 1998). Recent reviews of the med-
ical cost-offset literature for the treatment of depression indicate both that depression is associated
with increased use of medical services, and that treatment of depression can be expected to reduce
medical expenditures (e.g., Simon & Katzelnick, 1997; Thompson et al., 1998).
On the optimistic side of the cost-offset literature, research indicates that psychoeducation in the
form of cognitive behavioral therapies for somatic and medical disorders can prevent unnecessary
physician visits and dramatically reduce costs for services (Friedman, Sobel, Myers, Caudill, &
Benson, 1995). Ross, Hamilton, and Smith (1995) report that physicians can dramatically decrease
medical utilization and medical costs by treating psychological problems directly or by referring to
an appropriate mental health professional. In general, meta-analyses suggest that overall medical
expenditures are reduced by an average of 20% for psychological interventions (Chiles, Lambert, &
Hatch, 1999). However, no randomized controlled trials are currently available using only
depressed patients.
Group psychotherapy is a highly cost-effective treatment for depression and is a great deal less
expensive than providing medication. As discussed earlier, recent literature suggests that not only is
CBT as effective as medication treatments, but that this therapy sustains decreased depressive
symptomatology for longer periods, results in fewer relapses, and is much less expensive than phar-
macotherapeutic treatments (Antonuccio et al., 1997). For this reason, we propose that behavioral
health-care specialists encourage physicians to refer patients meeting criteria for depression to a
group CBT treatment rather than prescribing medications as a first-line treatment. (If physicians
determine that medication is the best strategy, this does not preclude the additional use of therapy,
which can reduce relapse rates following medication discontinuation.)
As a basic illustration of the cost-effectiveness of an 8-week group treatment of depression com-
pared with an 8-week course of pharmacotherapy alone (which we recognize is a substandard dos-
ing period), we offer a financial breakdown of potential savings for 300 patients as shown in Table
3.1. These figures make specific assumptions about the cost of paying a therapist hourly for deliver-
ing the group treatment and writing session notes. The calculations for the therapist’s per-hour rate
assume a base salary of $55,000 per year or $26.44 per hour. We will use the generic form of Prozac
(fluoxetine), which is estimated at $8.50 per week, based on an average of price quotes at national
pharmacies for a standard dosage of this medication. Currently, SSRIs such as Prozac are most
frequently prescribed for the treatment of depression. Only two SSRIs are available in the generic
form (fluoxetine and fluvoxamine), while all other SSRIs and other atypical antidepressants are not
available in the generic form. In the case where generic medications are unavailable, patients or
managed health-care companies must pay full price for these name-brand medications. We have
tried to make balanced conservative estimates of price for both treatment conditions.
Table 3.1 shows that if there are 10 patients per group in the therapy condition, and one
therapist sees six groups per week, it would take five therapists to see 300 patients in 8 weeks. We
have included the cost of the treatment manuals given to the patients and group leaders at an
estimated $5 per manual. At these rates, 300 patients seen in the psychosocial intervention condition
would cost $17,389 total, or $58 per patient. In contrast, 300 patients prescribed the SSRI (Prozac)
TABLE 3.1 Comparison of Psychosocial Intervention Versus Pharmacotherapy for 300 Patients for 8 Weeks
Group Treatment Costs Medication Costs
Therapist per hour rate (based on $26 Physician rate per hour (based on $75
$55,000/yr) $150,00/yr)
Per session cost based on 2-hour $66 Two medication visits per patient in $150
sessions +.5 hr notes, etc. 8 weeks
Per therapist per group of 10 patients $529 Total cost for psychiatrist visits for $45,000
with 8 sessions at 2.5 hrs 300 patients
Per therapist cost for 60 patients in $3,173 Cost per week for fluoxetine (generic for $8.50
6 groups run by 1 therapist Prozac)
Total cost for all therapists with $15,864 Cost per week for 300 patients on $2,550
5 therapists for all 8 sessions fluoxetine
300 manuals for patients + 5 therapists $1,525 Total cost for 300 pts for 8 weeks of $20,400
fluoxetine
Total cost for 300 patients for 8 weeks $17,389 Total cost for 300 pts for 8 weeks of $65,400
of treatment medication with physician visits
TOTAL COST per patient for 8 weeks $58 TOTAL COST per patient for 8 weeks of $218
of treatment treatment
for 8 weeks with two medication management visits with a physician (at $75 per hour based on a
salary of $150,000 per year) would cost a total of $65,400, or $218 per patient.
Notice that these figures could range even higher for medication costs. At least two factors would
greatly increase the costs of the pharmacotherapeutic intervention. First, the treatment duration is
not likely sufficiently long. It is more likely that patients would take an SSRI for 16 weeks or longer,
increasing the cost for 300 patients to $130,800, or $436 per patient using the generic drug, fluoxetine.
Second, the most commonly prescribed antidepressant at the time of this printing was Zoloft
(sertraline). Using these calculations for 8 weeks of treatment, the total cost for 8 weeks of treat-
ment for 300 patients on Zoloft would be $87,000, or $290 per patient, a figure five times that of
per-patient costs for psychotherapy.
Not all patients will be provided with only a psychosocial intervention. Some patients will desire
a pharmacological intervention, and some physicians may feel it is a necessary part of the
treatment. Still, if even a fraction of patients were referred to a group therapy intervention and not
prescribed antidepressants, there would be substantial cost savings.
Quality Assurance
One of the advantages of using a cognitive behavioral intervention lies in the ongoing assessment of
patient outcome. Many treatment outcome studies and manualized interventions advocate the
continual assessment of progress as well as pre- and post-treatment assessments. We recommend
that behavioral health-care specialists who provide a group or individual psychosocial treatment for
depression employ weekly assessments of patient progress for all patients.
The BDI and BDI-2 as described above make excellent, easy to use, weekly assessment instru-
ments. These devices are generic to patients and symptom-specific as well as sensitive to changes in
depressive behaviors. We also advocate the use of weekly self-report ratings of mood such as the
Daily Mood Scale developed by Muñoz and colleagues (Muñoz & Miranda, 1986). Patients are
instructed to rate their mood each day on a scale of +5 to negative 5, with 0 being the patient’s
average, nondepressed day.
Obtaining consistent data for patients prior to, during, and following treatment serves multiple
functions. First, it provides data to the patient about his or her progress in treatment. Second, the
therapist can use these data to inform adjustments to the treatment as necessary. For example, if the
patient made considerable progress in one area of treatment and then showed slowing in changes in
the BDI scores, the behavioral health-care specialist could revisit these areas in an attempt to capi-
talize on changes made earlier (Callaghan, 2001). Third, these data can be used to directly commu-
nicate information about patient progress to physicians and managed care companies. Data can be
presented as summary scores or graphically to indicate the direction of change over the course of
treatment. Summaries of all patients could be averaged across time, providing information about
the effectiveness of the intervention for a given population.
In the case of a lack of sufficient improvement, the therapist can consult with physicians to
determine if an adjunctive pharmacotherapy intervention should be employed. If the patient is
already taking a prescribed medication, an adjustment in dosage or type might be warranted.
In any case, it is crucial that the therapist collect data to provide accountability for service provision
to the patient, the physician with whom he or she is collaborating, and any managed behavioral
health-care organization that requires information about the progress of patients.
Summary
We have described depression here as a complex biopsychosocial phenomenon. Despite the
preponderance of antidepressants as a first-line treatment for depression, the empirical literature is
clear that this is only one of many possible treatments, and that pharmacological treatments may
not be the best choice of interventions for depression in a primary care setting. We advocate for the
role of the behavioral health-care specialist as a central figure in the assessment and treatment of
depressive disorders. This role will help ensure more accurate identification of depressed patients
and a more effective treatment approach.
We have described a possible model for the integrated care of depressed patients. This model is
one of many different options available to the behavioral health-care provider. Although we have
emphasized a cognitive behavioral model for the psychosocial intervention, we suggest that any
empirically supported therapy could easily be substituted. The key to this model is a group-based
intervention that can be conducted over a relatively short period of time. Another essential ingredi-
ent to success is the ongoing collaboration between the behavioral health-care specialist and the
primary care physician or other health-care agency. The consistent use of data provides important
evidence for the success of the intervention and the necessary role of the behavioral care provider.
Finally, continued focus on the cooperation of patients will help ensure that they are getting the
most out of the intervention.
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Zich, J. M., Atkisson, C. C., & Greenfield, T. K. (1990). Screening for depression in primary care clinics: The CES-D and the
BDI. International Journal of Psychiatry in Medicine, 20, 259–277.
Suggested Reading/Websites for Depression

Suggested Reading
Burns, D. D. (1999). Feeling good: The new mood therapy. Avon.
Klein, D. F., & Wender, P. H. (1994). Understanding depression: A complete guide to its diagnosis and treatment.
Oxford Press.
Papolos, D. (1997). Overcoming depression (3rd ed.). Quill Press.
Websites for Depression

Depression consumer information: http://www.depression.com/
National Alliance for Mentally Ill: http://www.nami.org/
National Institute of Mental Health: http://www.nimh.nih.gov/publicat/depressionmenu.cfm
Chapter 4
Anxiety Disorders in Primary Care
LAURA CAMPBELL-SILLS, JESSICA R. GRISHAM, AND TIMOTHY A. BROWN
Relevance, Epidemiology, and Cost of Anxiety Disorders in Primary Care

Individuals with anxiety disorders frequently seek medical care from a primary care physician for
the treatment of their somatic symptoms (Katon, 1984; Kennedy & Schwab, 1997; Roy-Byrne,
1996). Because anxiety symptoms often resemble those associated with various medical conditions,
patients may present with cardiac, neurological, or gastrointestinal complaints such as chest
pain, palpitations, diarrhea, headache, or dizziness (see Table 4.1). Patients with anxiety disorders
are also more likely to have specific co-morbid medical disorders such as angina, mitral valve
prolapse, hypertension, peptic ulcer disease, or thyroid disease (Rogers et al., 1994). An anxiety
disorder may exacerbate an underlying medical illness (e.g., coronary artery disease or asthma), or
may mimic symptoms of a medical illness (Karajgi, Rifkin, Doddi, & Kolli, 1990; Kawachi et al.,
1994; Rogers et al., 1994).
Recent epidemiological studies, such as the Epidemiological Catchment Area (ECA) Study and
the National Comorbidity Study (NCS), have found 1-year prevalence rates of anxiety disorders of
12.6% and 17.2%, respectively (Kessler et al., 1994; Regier et al., 1993). With respect to primary
care settings, a report from the World Health Organization on anxiety syndromes in five European
primary care settings found that 15.6% of patients suffered from an anxiety disorder (Weiller,
Bisserbe, Maier, & Lecrubier, 1998). A U.S. study found a similar current prevalence of 14.6% and a
lifetime prevalence of 23.9% in primary care settings (Nisenson, Pepper, Schwenk, & Coyne, 1998).
Approximately 50% of patients with anxiety and mood disorders receive their mental health care
in primary care settings (Harman, Rollman, Hanusa, Lenze, & Shear, 2002; Regier et al., 1993), and
some evidence suggests that these patients receive suboptimal care. In a study of office visits for
anxiety disorders from 1985 to 1998, Harman et al. (2002) found that treatment was offered by pri-
mary care clinicians in only 54% of visits that coded for a specific anxiety diagnosis. This statistic
contrasted with the rate of treatment offered by psychiatrists who prescribed treatment in 95% of
such visits. Furthermore, the rate of anxiety treatment in primary care is significantly lower than
the rate of treatment that corresponds to depression-related visits (82%; Harman, et al., 2002).
Anxiety is often associated with considerable impairment and can affect the outcome and cost of
medical treatment (Fifer et al., 1994; Ormel, Oldehinkel, Brilman, & van den Brink, 1993;
Sherbourne, Jackson, Meredith, Camp, & Wells, 1996). Owing to the strong somatic component of
87
TABLE 4.1 Medical Conditions That May Cause or Resemble Anxiety

Type of Medical Condition Examples of Specific Conditions
Endocrine Hyper- and Hypothyroidism
Pheochromocytoma
Hypoglycemia
Hyperadrenocorticism
Cardiovascular Congestive Heart Failure
Pulmonary Embolism
Arrhythmia
Mitral Valve Prolapse
Respiratory Asthma
Chronic Obstructive Pulmonary Disease
Pneumonia
Hyperventilation
Metabolic Vitamin B12 Deficiency
Porphyria
Neurological Neoplasms
Vestibular Dysfunction
Encephalitis
Seizure Disorders
Substance Intoxication Alcohol, Amphetamine, Caffeine, Cannabis, Cocaine, Hallucinogens,
Inhalants, Phencyclidine, and Others
Substance Withdrawal Alcohol, Cocaine, Sedatives, Hypnotics, Anxiolytics, and Others
Other Pregnancy
Perimenopause
anxiety, the presence of an anxiety disorder may contribute to the development of certain medical
conditions and may be a barrier to optimal care and treatment response (Klerman, Weissman,
Ouellette, Johnson, & Greenwald, 1991; Ormel et al., 1993). Economic analyses suggest that
patients with anxiety disorders tend to overutilize health-care services and resources (Roy-Byrne,
1996). Patients who are repeatedly evaluated or treated for a physical symptom that is a manifesta-
tion of an anxiety disorder (e.g., palpitations) may be inefficiently using health-care resources
without achieving lasting relief from their illnesses.
A study by Kennedy and Schwab (1997) examined the utilization of medical specialists by 80
anxiety disorder patients and 14 nonanxious adults in a 5-year period. Interestingly, the type of
medical care sought by anxiety patients depended somewhat on the type of disorder. Although
patients with panic disorder (PD) frequently were seen in primary care family medicine and by
neurology specialists, patients with generalized anxiety disorder (GAD) were often seen by gastro-
enterologists, presumably due to physical conditions, such as irritable bowel syndrome, that
frequently accompany chronic tension and anxiety (Kennedy & Schwab, 1997). The results also
suggested that medical utilization of patients with PD was particularly high, with 83% of these
patients seeing their primary care physicians compared with 36% in the control group. Similarly,
Leon, Portera, and Weissman (1995) analyzed data from the ECA Study (Regier et al., 1993) and
found that nearly 30% of individuals with PD had used the general medical system for emotional,
alcohol, or drug-related problems in the 6 months prior to the study interview. Furthermore,
Anxiety Disorders in Primary Care • 89
individuals with any anxiety disorder were more likely than nonanxious individuals to seek help
from emergency rooms.
Simon, Ormel, VonKorff, and Barlow (1995) also examined the overall health costs associated
with anxiety and depression among 2,110 primary care patients in a health maintenance organization
(HMO). The results indicated that primary care patients with anxiety or depressive disorders had
significantly higher baseline costs ($2,390) than patients with no anxiety or depressive disorder
($1,397). These cost differences reflected higher utilization of general medical services rather than
higher mental health treatment costs and persisted after adjusting for medical morbidity.
In addition to costs associated with health-care overutilization, the prevalence of anxiety disor-
ders in the community also results in substantial social costs. Patients with anxiety disorders are
often impaired emotionally, physically, and economically, resulting in the social costs of decreased
productivity and increased unemployment (Olfson et al., 1997). Leon et al. (1995) found that men
with PD, phobias, or obsessive-compulsive disorder (OCD) were more likely to be chronically
unemployed and to receive disability or welfare. In addition, Telch, Schmidt, Jaimez, Jacquin, and
Harrington (1995) found that PD patients displayed significant impairment in quality of life.
Co-morbidity of anxiety with other mental disorders also affects health-care outcome and costs.
Anxiety and depression often co-occur, with co-morbidity rates of major depression with PD and
GAD in primary care settings that range up to 60% (Brown, Schulberg, Madonia, Shear, & Houck,
1996). Co-morbid depression and anxiety are associated with greater severity of depression, poorer
psychosocial functioning, and poorer treatment outcomes (Coryell, Endicott, & Winokur, 1992),
and may also be associated with particularly high health-care costs. Brown et al. (1996) showed that
patients treated for depression with a co-morbid anxiety disorder took longer to recover, and those
with lifetime PD showed a lack of response to pharmacotherapy and psychotherapy. To overcome
the obstacles involved in treating depressed primary care patients with co-morbid anxiety, several
researchers (Coplan & Gorman, 1990; Fawcett, 1990) have suggested evaluating and treating the
symptoms of anxiety as soon as the patient begins treatment to improve compliance with antide-
pressant medication.
Successful treatment may produce not only significant medical cost offsets, but also meaningful
improvements in quality of life. Salvador-Carulla, Segu, Fernandez-Cano, and Canet (1995)
assessed the costs before and after the provision of effective treatment for PD. They measured lost
workdays, health-care services used, and patients’ assessment of general functioning, improvement,
severity of symptoms, and level of disability. Overall, the authors found a 94% offset in these costs
associated with PD with effective treatment.
Although more research is needed on treatment of anxiety disorders in primary care, timely
recognition, accurate diagnoses, appropriate treatment, referral, and support are likely to reduce
the financial burden of anxiety-related visits in primary care and to medical specialists. Moreover,
the movement toward integrating mental health services into primary care settings may produce
additional reductions in cost. A cost-effectiveness study of an English community mental health
service based in primary care compared costs of services for patients with new episodes of anxiety
and depression treated either in the mental health service or the traditional hospital-based service.
The patients seen by the community primary care service incurred lower health services costs and
were more satisfied with their treatment than patients seen by the hospital service, even when
controlling for illness severity (Goldberg, Jackson, Gater, Campbell, & Jennett, 1996).
The integration of mental health services into primary care settings is often labeled collaborative
care. Roy-Byrne, Katon, Cowley, and Russo (2001) tested a collaborative care intervention for PD
against usual care in three primary care clinics. The collaborative care intervention consisted of
sending educational materials about PD and medication to patients, scheduling two psychiatrist
visits and two phone contacts in the first 8 weeks of medication treatment, and providing up to
five additional phone calls within the 12-month follow-up period. Patients who received the
collaborative care intervention were more likely to receive adequate medication and to comply with
treatment recommendations. These patients also manifested greater symptom improvement and
less disability, particularly in the first 3 to 6 months of the treatment phase. Furthermore, the
collaborative care intervention was cost-effective (Katon, Roy-Byrne, Russo, & Cowley, 2002).
Patients who received the intervention had an average of 74 fewer anxiety-free days and no signifi-
cant differences in outpatient costs. There was a 70% probability that collaborative care was a
“dominant” intervention (i.e., more effective and less expensive), with a savings of $4 per anxiety-
free day (Katon et al., 2002).
In summary, the evidence demonstrating the high prevalence and cost of anxiety disorders in
the community emphasizes the need for the accurate assessment, treatment, and prevention of
anxiety disorders in primary care settings. Because of the close interaction between mental and
physical components of anxiety, patients with anxiety disorders should be viewed from an integra-
tive perspective that identifies psychological, social, and physiological vulnerabilities, stressors, and
symptoms. Clinical research is beginning to elucidate strategies that are tailored to primary care
settings that may help to achieve this ideal.
Assessment of Anxiety Disorders
The Challenges of Establishing a Diagnosis

Primary care settings are often the first point of assessment of a patient’s anxiety difficulties.
The task of assessment is complicated by the fact that patients vary considerably in their presenta-
tions and often emphasize somatic rather than psychological distress. Anxiety may be accompanied
by symptoms such as heart-racing or palpitations, shortness of breath, dizziness, muscle tension,
insomnia, and a variety of other physical sensations (see Table 4.2). Patients who experience panic
attacks or generalized anxiety may attribute their symptoms to an underlying physical problem,
and therefore they consult a medical doctor rather than a mental health clinician. The primary care
clinician must often rule out possible medical problems before making a conclusive anxiety disor-
der diagnosis. A second level of differential diagnosis involves determining which anxiety disorder
diagnosis best describes the patient’s problems. Primary care providers may have difficulty with this
second level of differential diagnosis, in that the majority of primary care visits for anxiety disorders
are coded “anxiety state, unspecified” (Harman et al., 2002).
With regard to the first level of differential diagnosis (distinguishing anxiety from physical disor-
ders), PD stands out as being particularly susceptible to interpretation by both patient and clinician
as a physical problem. Indeed, one need only peruse the diagnostic criteria for a panic attack to
understand why patients assume that something is wrong with them physically. The presence of
sensations associated with autonomic arousal is compounded by the tendency of patients with PD
to interpret these sensations in a catastrophic manner. Common interpretations of panic symptoms
include beliefs that one is having a heart attack, stroke, or fainting spell. Thus, patients often
present to the emergency room or to primary care facilities in extreme distress over what they
perceive as a dangerous heart condition or neurological problem.
Primary care clinicians who encounter patients complaining of persistent bouts of uncomfort-
able physical sensations typically evaluate many aspects of the patient’s physical functioning.
Anxiety can produce symptoms resembling cardiac, respiratory, and neurological disorders as well
as pregnancy (Spiegel & Barlow, 2000). At times, a physical condition can explain the patient’s
symptoms and be successfully treated via medical intervention. However, in many cases diagnostic
test results are negative and an assessment of anxiety or other psychological problems is necessary.
TABLE 4.2 Somatic Symptoms Commonly Associated With Anxiety

Type of Anxiety Specific Symptoms*
Panic Attack Palpitations
Accelerated Heart Rate
Sweating
Trembling
Shortness of Breath
Choking Sensations
Chest Pain
Nausea
Abdominal Distress
Dizziness, Lightheadedness, Imbalance
Paresthesias
Chills
Hot Flushes
Generalized Anxiety Insomnia

Fatigue
Muscle Tension
Restlessness
*Both panic attacks and generalized anxiety can accompany the full range of anxiety disorders. These symptoms are not
diagnostic of any specific anxiety disorder.
Although PD is the anxiety disorder with the most obvious physiological component, other
anxiety disorders are also encountered in primary care. Empirical studies suggest that GAD is very
frequently encountered in primary care settings (e.g., Shear & Schulberg, 1995). Associated symp-
toms of GAD include restlessness, fatigue, irritability, insomnia, concentration problems, and
muscle tension. It has been noted that many anxious patients who present to primary care physi-
cians do not meet full diagnostic criteria for GAD, but rather exhibit “subsyndromal” generalized
anxiety or mixed anxiety-depression (Katon & Roy-Byrne, 1991; Olfson et al., 1996; Rickels &
Schweizer, 1997). These individuals will likely emphasize physical problems when presenting to a
primary care doctor, and it may take knowledgeable probing about psychological factors to deter-
mine if the problem is anxiety based.
Even when a diagnosable physical condition is present, this does not rule out the possibility of a
coexisting anxiety disorder. Physicians must consider whether the patient’s level of subjective
distress or impairment exceeds that which would be expected given the medical diagnosis. For
example, some patients with benign heart conditions experience considerable distress and life inter-
ference due to their fear of the physical sensations that arise on occasion. They may avoid activities
or situations due to concerns about provoking symptoms, even though these symptoms are not
harmful. In these cases, a co-morbid anxiety diagnosis may be appropriate.
Performing a Preliminary Assessment of Anxiety

An anxiety assessment should be part of the primary care evaluation when the patient’s distress is
either (1) not explained by any underlying physical problem, or (2) not fully explained by any
underlying physical problem (e.g., in the case of a patient whose life is drastically altered by
a benign medical condition). The first requirement for an adequate anxiety assessment is a thorough
understanding of the criteria that define the various anxiety disorders in the Diagnostic and Statis-
tical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994).
Knowledge of the diagnostic criteria allows the primary care clinician to conduct an efficient pre-
liminary assessment of the patient’s problem.
The primary care clinician who is armed with knowledge about the characteristics of various
anxiety disorders is prepared in one important sense. However, this technical knowledge may be
to no avail if the topic of anxiety is not approached in a sensitive, nonthreatening manner. Indeed,
patients who present to primary care clinicians rather than mental health professionals may
be those who are most resistant to a psychological conceptualization of their problems. Although
anxiety disorders are quite prevalent in the general population, the stigma associated with
psychological problems remains, and it may influence patients’ descriptions of their difficulties
(Roy-Byrne & Katon, 2000). Primary care physicians must approach inquiry about psychological
problems in a delicate and empathic manner. It is probably worth the time to spend a few minutes
discussing the relationships between psychological stress and physical symptoms, as well as reassur-
ing the patient that such problems are common and treatable. Doctors may also need to reinterpret
psychological problems for patients who think that having an anxiety disorder means they are
“crazy” or that their physical symptoms are not real. An example of this type of feedback follows:
We have completed numerous tests for physical problems and each one has come back nega-
tive. I know this may be frustrating for you, since you are certainly experiencing physical
discomfort. However, it does not appear that any cardiac or gastrointestinal disease is causing
your unpleasant symptoms. Sometimes we think of mind and body as being completely
separate, but in fact they are very intricately related. For example, sometimes people have
stomach trouble or headaches when they are under stress or having personal problems.
I wonder if some of your physical symptoms might be the result of stress or psychological
factors. If they are, that would be important to know because there are effective treatments
out there for such problems that could alleviate your symptoms. Would it be all right if
I asked you some questions to find out if this type of treatment might be helpful for you?
Before moving into specific questions concerning anxiety or other psychological problems, the
clinician should review the rules pertaining to doctor-patient confidentiality. Patients who
understand the breadth and limits of confidentiality are more likely to feel at ease discussing psy-
chological difficulties.
The DSM-IV diagnostic criteria can form the basis for the screening questions that are necessary
for rapid assessment. Structured diagnostic interviews for anxiety disorders often include such
questions, although their length precludes them from being fully administered in a primary care
appointment. However, these interviews can be a useful source of ideas about how to ask patients
about psychological problems and for choosing questions that are likely to lead to accurate diagno-
sis (Brown, Di Nardo, & Barlow, 1994; First, Gibbon, Spitzer, & Williams, 1996). For example, the
patient who reports alternation between restlessness, headaches, and insomnia (symptoms of
generalized anxiety) might be asked, “Do you tend to worry frequently about many different life
matters?” or “Do you ever feel that it is hard to put your worries aside when you would like to focus
on other things?” Excessive, uncontrollable worry is the defining feature of GAD and thus should
be a subject of inquiry. Possible screening questions for all of the major anxiety disorders are
presented in Table 4.3.
If a patient endorses a problem that seems to fit the criteria for an anxiety disorder, then two
approaches may be taken. The first is to refer the patient for a comprehensive anxiety evaluation by
TABLE 4.3 Screening Questions for Commonly Diagnosed Anxiety Disorders

Disorder Possible Screening Questions
Panic Disorder “Do you experience sudden unexpected rushes of fear accompanied by
uncomfortable physical sensations?” If yes: “When do you tend to have
these feelings? In what kinds of situations?” If the patient reports attacks
that are circumscribed to one type of situation (e.g., social situations): “Do
the rushes of fear ever come unexpectedly or in situations that do not
involve ___________(e.g., public speaking)?” If yes, probe further for
panic disorder. If no unexpected attacks, consider other diagnoses.
Agoraphobia “Are you avoiding any situations or feeling apprehensive about doing
certain things due to fears of becoming panicky or having uncomfortable
sensations?” If yes: “Which types of situations?” Again, probe to determine
if the avoidance is circumscribed enough to assign another diagnosis (e.g.,
social phobia).
Social Phobia “Do you feel anxious or nervous about interacting with or speaking in front
of other people?” “Do you often worry about embarrassing yourself in
front of others?”
Generalized Anxiety Disorder “Do you frequently worry about many aspects of your life?” “Do you often
find yourself worrying about things that most people would call ‘minor
matters’?” “Is it difficult for you to stop worrying for a while to focus on
other activities?”
Obsessive-Compulsive “Do you ever have unwanted or intrusive thoughts or images that keep
Disorder recurring to you?” “Do these thoughts or images bother you a great deal or
seem inappropriate?” “Do you ever feel driven to repeat some behavior
over and over again or until it feels ‘just right’?”
Specific Phobia “Do you have any strong fears of objects or situations, or do you feel the
need to avoid anything at all costs?”
Posttraumatic Stress Disorder “Have you ever experienced or witnessed a traumatic or life-threatening
situation?” “Do you ever have intrusive memories, thoughts, or dreams
about those experiences that upset you?”
a specialist. Alternatively, the primary care clinician can undertake the task of differentiating
between the various anxiety diagnoses. This is an extremely important phase of diagnosis, because
distinct empirically supported treatments exist for each anxiety disorder. Clinicians must also
consider other psychological problems that share common features with anxiety, such as mood
disorders and somatoform disorders. To illustrate the challenges of differential diagnosis, two
apparently straightforward symptoms—panic attacks and worry—will be discussed in terms of
their relation to various psychiatric diagnoses.
The Context of Panic Attacks

Establishing the context in which panic attacks occur is very important, because “panic attack” is
not a psychiatric diagnosis. Panic attacks can be associated with any of the anxiety disorders
(Barlow, Brown, & Craske, 1994), and in only a subset of cases is the diagnosis of PD appropriate.
Clinicians must establish whether attacks occur unexpectedly across situations or if they occur
exclusively in the context of a specific situation. For instance, individuals with social phobia or
specific phobia often experience panic attacks, but these attacks are always cued by the presence of
the feared stimulus (e.g., air travel, driving, public speaking). On the other hand, individuals who
receive a diagnosis of PD experience at least some “out of the blue” panic attacks that are not
predictable based on a specific feared situation.
Panic attacks can also occur in the context of GAD, and these attacks may be difficult to distin-
guish from the unexpected attacks that characterize PD. However, upon careful examination it
becomes clear that the patient with generalized anxiety experiences attacks as the culmination of
intense worry. Patients sometimes describe “working themselves into a panic attack” and
emphasize the content of the worry rather than the panic symptoms as the key feature of the
experience. Similarly, individuals with OCD may experience panic attacks when exposed to the
content of their obsessions or when prevented from engaging in compulsive behaviors (e.g., when
confronted with a contaminant or when prevented from checking an appliance). Once again, the
focus of the patient’s distress is likely to be the exposure to the obsessional content rather than
the symptoms of anxiety.
It is also very important to determine if panic attacks are occurring in response to internal or
external traumatic cues, as in the case of individuals with posttraumatic stress disorder (PTSD).
Patients with a trauma history often experience autonomic arousal and even full-blown panic
attacks when confronted with intrusive recollections or external cues that remind them of the
traumatic event. Treatment for PD would not be helpful for most of these individuals because the
provocative traumatic material would be left unaddressed.
In summary, it is important to recognize that panic attacks can be a feature of almost any anxiety
disorder. Particularly when presenting to primary care, patients may focus on descriptions of panic-
like symptoms because it is more culturally acceptable to discuss physical problems with a doctor. If
it becomes clear that a patient is experiencing panic attacks, it is important to determine the greater
context surrounding them to facilitate accurate diagnosis and appropriate treatment selection.
The Content of Worry

Like panic attacks, worry can be a characteristic of many anxiety disorders. Excessive, uncontrolla-
ble worry about many different life matters is the central feature of GAD and therefore clinicians
may be inclined to assign this diagnosis if a patient describes him- or herself as a worrier. However,
upon further inquiry it may become apparent that the focus of the patient’s worry is too circum-
scribed to merit a diagnosis of GAD. Socially anxious individuals worry tremendously about
upcoming social encounters, but may worry little about finances or health. People with PD may
worry continually about when their next attack will occur; however, this should be considered a
feature of PD rather than GAD. Clinicians will recognize that individuals who truly have GAD
worry about many different areas of their lives, such as minor matters, health, relationships, work,
and finances. If a patient reports worry about one aspect of his or her life, the clinician should
probe further to achieve a picture of how diffuse the worry content is. If the worry can be better
accounted for by a more specific anxiety disorder, then GAD should not be assigned.
Generalized anxiety also shares common features with mood disorders, which are also
commonly encountered in primary care settings. In general, it is good practice to inquire about
depressed mood if patients endorse anxiety symptoms, because mood and anxiety disorders are
frequently co-morbid (Brown & Barlow, 1992; Brown, Campbell, Lehman, Grisham, & Mancill,
2001; Wittchen, Zhao, Kessler, & Eaton, 1994). This is particularly important in the case of GAD
because many of its associated symptoms overlap with symptoms of depression. In fact, DSM-IV
precludes assigning a diagnosis of GAD if the worry and tension occur exclusively during the course
of a mood disorder. To facilitate selection of appropriate treatment, the primary care clinician
should determine whether the patient’s predominant mood involves worry and tension, or sadness
and hopelessness.
Judging the Severity of the Problem

Depending on the severity of the anxiety problem, different levels of treatment may be indicated.
For individuals in extreme amounts of distress, inpatient or intensive outpatient treatments may be
the best option. For other patients, weekly outpatient sessions or self-directed therapy may be
sufficient to treat the problem. Because efficient allocation of resources is a major issue in primary
care, assessing the severity of the presenting problem is quite important. Patients who require
intensive treatment should not be referred for brief, weekly outpatient therapy that is bound to fail.
Likewise, it is important to recognize those patients who need a minimal amount of direct attention
from the clinician, so that clinical hours are open for those who require more support. Appropriate
allocation of resources begins with an accurate judgment of the severity of the patient’s anxiety
problem. The patient’s level of subjective distress and the objective amount of life interference both
contribute to an estimation of severity.
Primary care clinicians will likely get one sample of the patient’s subjective distress in the
consulting room. However, it is also important to ask how much the patient feels bothered by the
problem on an ongoing basis. Does it cause him or her distress every day? For most of the day?
Or does the problem only enter the patient’s awareness occasionally? Patients with severe anxiety
disorders often feel consumed by anxiety, and they report a tremendous amount of subjective
distress. On the other hand, some patients feel that their anxiety is manageable for long periods of
time and then becomes exacerbated (e.g., when under stress). These varying levels of distress influ-
ence the clinician’s appraisal of the disorder severity.
Anxiety disorders frequently interfere with people’s work, relationships, and leisure activities.
Simply asking the patient, “In what ways has the anxiety interfered with your life?” is likely to
provide useful information about the degree of life interference. Many patients function extremely
well despite anxiety problems, and they typically describe few limits on their work and leisure.
Others are truly debilitated by anxiety and are unable to sustain relationships or employment due
to the severity of their disorders. Striking examples include the patient with agoraphobia who is
housebound, and the individual with social phobia who must quit his or her job or drop out of
school due to fear of interacting with others. Patients who do not elaborate spontaneously on the
ways that anxiety affects their lives should be asked directly about the effects of anxiety on their
work, relationships, leisure activities, and overall quality of life.
Tools That Aid in Anxiety Diagnosis

The financial and time pressures associated with primary care settings constrain the assessment
process in important ways. Many useful forms of assessment, such as structured interviews and
behavioral assessment, are simply not feasible in primary care settings. Therefore, this section of the
chapter will focus on tools that aid in rapid assessment. When used in conjunction with a
professional’s carefully selected questions, these assessment tools should facilitate reliable and valid
diagnosis. However, rapid assessment can be risky—particularly when dealing with a group of
disorders that have overlapping features (see section above on differential diagnosis). Given that
distinct empirically supported treatments exist for each of the anxiety disorders, accurate assess-
ment results may truly mean the difference between effective and ineffective treatment. The best
protection against misdiagnosis is an understanding of key features that differentiate among the
disorders and a willingness to continue assessment beyond the initial meeting with the patient. As
with any other diagnostic process, clinicians should be alert for further information that converges
with or contradicts their initial impressions.
Once the primary care professional suspects that a patient’s presenting problem is anxiety based, a
preliminary conceptualization is developed through screening questions and unstructured questioning.
As noted above, the DSM-IV and structured clinical interviews may serve as resources for generation
of screening and follow-up questions (see Table 4.3). In order to obtain additional evidence for diag-
nosis, clinicians may elect to utilize brief self-report inventories that target different types of anxiety
symptoms. A number of self-report instruments have sound psychometric properties and are simple
to administer and score. Table 4.4 presents a number of these questionnaires, as well as the anxiety
disorders for which they are most relevant.
Some recent efforts have been focused on developing screening measures for anxiety that are
specifically intended for use in primary care clinics. This approach envisions the screening process
occurring in the waiting room before patients see their provider; in addition, the provider can use
the information obtained in the screening to streamline their consultation. The Beck Anxiety
Inventory for Primary Care (BAI-PC) is a seven-item scale that employs a cutoff score of 5 for
detection of clinically significant anxiety (Beck, Steer, Ball, Ciervo, & Kabat, 1997). Using this cutoff
score, the BAI-PC successfully identifies approximately 85% of patients with clinical anxiety disor-
ders, while screening out about 80% of those individuals who do not have clinically significant anx-
iety (Beck et al., 1997; Mori et al., 2003). Mori et al. (2003) also report that the BAI-PC is a useful
measure for detecting cases of depression and PTSD.
Questionnaire developers face a challenge in balancing brevity with diagnostic accuracy. Very
brief questionnaires are often effective in detecting cases of a disorder, but tend to generate many
false positives as well. For example, a two-question screen for PD was reported to have excellent
sensitivity (catching 94–100% of true PD cases) but poor specificity (screening out only 25–59% of
true negative cases; Stein et al., 1999). The finding that clinicians could be alerted to most true cases
of PD on the basis of just two questions is impressive. However, the low specificity of the screen
TABLE 4.4 Self-Report Instruments for Measuring Anxiety

Questionnaire # Items Relevant Disorders*
Albany Panic and Phobia Questionnaire (Rapee, Craske, & 27 PD, Social Phobia
Barlow, 1995)
Anxiety Sensitivity Index (Peterson & Reiss, 1992) 16 PD
Autonomic Nervous System Questionnaire (Stein et al., 2 PD
1999)
Beck Anxiety Inventory (Beck & Steer, 1990) 21 PD, GAD
Beck Anxiety Inventory for Primary Care (Beck, Steer, Ball, 7 PD, GAD
Ciervo, & Kabat, 1997)
Depression Anxiety Stress Scales (Lovibond & Lovibond, 42 PD, GAD, Depression
1995)
Maudsley Obsessive-Compulsive Inventory (Hodgson & 30 OCD
Rachman, 1977)
Penn State Worry Questionnaire (Meyer, Miller, 16 GAD
Metzger, & Borkovec, 1990)
Posttraumatic Diagnostic Scale (Foa, Cashman, 17 PTSD
Jaycox, & Perry, 1997)
PTSD Checklist (Weathers, Litz, Herman, Huska, & 17 PTSD
Keane, 1993)
Social Interaction Anxiety Scale (Mattick & Clarke, 1998) 20 Social Phobia
*PD = panic disorder; GAD = generalized anxiety disorder; OCD = obsessive-compulsive disorder; PTSD = posttraumatic
stress disorder.
creates an efficiency problem, in that providers will spend time assessing for PD in many patients
who screened positive but do not actually have the disorder.
In addition to these disorder-specific questionnaires, general screening instruments for psycho-
logical problems have recently become available for use in primary care settings. Two of the more
popular interviews are the Primary Care Evaluation of Mental Health Disorders (PRIME-MD;
Spitzer et al., 1994) and the Mini-International Neuropsychiatric Interview (MINI; Sheehan et al.,
1998). Each of these interviews includes a self-report symptom checklist that patients complete
before meeting with their clinician. Brief clinician-administered interviews are used to follow up
problem areas identified by the patient. The clinician-administered section can be administered
quite rapidly, with an average of 8.4 minutes for the PRIME-MD and 15 minutes for the MINI
(Sheehan et al., 1998; Spitzer et al., 1994). Closed-ended (yes or no) questions address symptoms of
DSM-IV anxiety disorders, and diagnosis simply requires a symptom count.
In general, interviews such as the PRIME-MD and MINI have adequate reliability and validity.
However, their sensitivity for detecting certain anxiety disorders is below the optimum level. With
regard to the PRIME-MD, 57% of PD and GAD cases (as diagnosed by mental health professionals)
were correctly identified by primary care clinicians using the PRIME-MD (Spitzer et al., 1994). The
developers of the MINI also compared diagnostic results using their screening instrument to expert
opinion. They found that 44% of PD cases and 67% of GAD cases identified by psychiatrists were
detected using the MINI (Sheehan et al., 1998).
Although the PRIME-MD and MINI allow for diagnosis of psychological disorders in signifi-
cantly less time than a full psychological evaluation, even a 10–15 minute interview may be too
time-consuming to be employed in a typical primary care setting. To remedy this problem, studies
are being conducted that investigate more time-efficient methods of administering these types of
screens. For example, a self-report version of the PRIME-MD (Patient Health Questionnaire; PHQ)
has been evaluated for use in primary care settings (Spitzer, Kroenke, & Williams, 1999). Initial
results suggest that diagnoses obtained from physicians’ reviews of PHQ were in good agreement
with diagnoses made by independent mental health professionals. In addition, physicians were
typically able to review the PHQ in less than 3 minutes, which represents a significant improvement
in time-efficiency over the clinician-administered version.
Another diagnostic tool that aims to decrease the time burden of assessment for primary care
providers is the Symptom Driven Diagnostic System for Primary Care (SDDS-PC; Weissman et al.,
1998). The SDDS-PC can be reliably administered by health care professionals other than doctors
(e.g., nurses). This tool first requires patients to complete a brief written questionnaire that screens
for depression, GAD, PD, OCD, alcohol- and substance-use disorders, and suicidality. A nurse then
administers a computerized diagnostic interview only for the disorders for which the patient
screened positive. Preliminary investigation suggests that nurses take approximately 1.5 to 3.6
minutes to complete the diagnostic interview, depending on the diagnosis being queried
(Weissman et al., 1998). The computerized interview subsequently produces a 1-page summary
report with provisional diagnoses that aids the primary provider in probing efficiently for mental
health problems.
Although use of the SDDS-PC produced moderate-to-excellent agreement between nurse and
primary care physician diagnoses, agreement between physicians using the SDDS-PC and mental
health professionals using a structured clinical interview was in the moderate-to-poor range for the
anxiety diagnoses (Weissman et al., 1998). Typically, primary care physicians and mental health
professionals agreed that the patient suffered symptoms of a particular diagnosis, but disagreed on
whether the patient met full criteria for that specific diagnosis. The actual clinical implications of
this type of disagreement remain unclear.
A final tool that may improve both efficiency and accuracy of primary care anxiety diagnoses is
the Quick PsychoDiagnostics Panel (QPD; Shedler, Beck, & Bensen, 2000). The QPD is unique in
that it is fully self-administered and therefore requires no clinician time for administration or scor-
ing. Patients complete true/false questions on hand-held computer units that are programmed to
screen for nine psychiatric disorders. The computer program is similar to a structured interview,
in that the progression of questions is based on patients’ answers to critical items (i.e., follow-up
questions are only asked if the probe items are endorsed). Shedler et al. (2000) report that the
QPD takes patients an average of 6.2 minutes to complete. A diagnostic report can be printed
immediately after questionnaire completion, which provides the clinician with scores indicating the
severity of disorder symptoms, provisional psychiatric diagnoses, and a list of the disorder
symptoms that the patient endorsed.
The QPD assesses for GAD, PD, and OCD. Like the other primary care interviews, it is currently
limited in that it does not assess for several other common anxiety disorders (e.g., PTSD, social
phobia). However, an initial study of the reliability, validity, and utility of the QPD suggests that
this instrument successfully assesses for GAD, PD, and OCD. The QPD demonstrated good sensi-
tivity and specificity in identifying cases of these anxiety disorders, and manifested good agreement
with diagnoses obtained by a well-validated structured clinical interview (Shedler et al., 2000).
The PRIME-MD, MINI, SDDS-PC, and QPD are promising steps toward adequate screening for
psychological problems in primary care. Clinicians who utilize these instruments may improve
their chances of accurate diagnosis by employing some of the other assessment strategies reviewed
in this chapter. In particular, differential diagnosis requires probing beyond that which is included
in basic screening instruments. If time permits, clinicians are advised to add questions to screening
instruments that help them determine the true focus of the patient’s anxiety problem.
Assessing Treatment Outcome and Quality Assurance

It is important to note that assessment does not end once the treatment phase begins. Some of the
same assessment tools described above can be used for monitoring the patient’s progress during
treatment. Brief questionnaires can be completed by the patient in the waiting room before each
appointment with the clinician. Scores from successive sessions can be plotted on graphs to provide
objective information about progress to patients, other clinicians, and third-party payers.
Combining questionnaire results with patient self-monitoring provides a more comprehensive
picture of progress throughout treatment. Patients may be asked to monitor variables such as levels
of anxiety, percentage of the day spent worrying, and avoidance of feared situations on a daily basis.
Patient’s reports of these indicators of anxiety severity can also be graphed over time to provide
another view of treatment outcome. Self-monitoring can also serve as a measure of treatment integ-
rity. For example, different monitoring forms can be used as documentation of the skills that the
patient is practicing as part of therapy (e.g., exposures, cognitive restructuring). The degree to
which the patient records treatment-relevant activities also demonstrates the level of compliance
with therapist instruction.
In summary, periodic use of objective measures and self-monitoring forms can aid in documen-
tation of treatment integrity, the assessment of treatment compliance, and providing evidence of
treatment efficacy. This serves to effectively communicate important aspects of treatment to other
clinicians and third-party payers.
Treatment of Anxiety Disorders

Many useful options exist for primary care clinicians who discover that a patient’s problems are anx-
iety related. Primary care clinicians overwhelmingly adopt a pharmacological approach to treatment
of anxiety (Harman et al., 2002); indeed, there are numerous medications that have been shown
to be efficacious for treating anxiety disorders (see Spiegel, Wiegel, Baker, & Greene, 2000, for a
review). However, the value of equally efficacious psychosocial treatments for anxiety disorders is
often unrecognized by primary care providers. For instance, cognitive-behavioral therapies that
have been proven to be effective for treating anxiety disorders remain a very infrequent recommen-
dation in primary care settings (Harman et al., 2002).
Efficacious psychosocial treatments now exist for all the major anxiety disorders, and handbooks
that outline the major treatment strategies for different anxiety disorders are available (e.g., Barlow,
2001; Nathan & Gorman, 1998). The psychological treatments with the most demonstrated success
in treating anxiety employ cognitive and behavioral techniques. The most recent list of empirically
supported treatments assembled by an American Psychological Association taskforce contains
14 treatments for anxiety disorders that are considered “empirically validated” or “probably effica-
cious,” as well as an efficacious treatment for coping with stress (Chambless et al., 1996). The
empirically validated treatments are (a) cognitive-behavioral therapy for panic and agoraphobia,
(b) cognitive-behavioral therapy for GAD, (c) group cognitive-behavioral therapy for social phobia,
(d) exposure treatment for agoraphobia, (e) exposure treatment for social phobia, (e) exposure and
response prevention for OCD, (f) stress inoculation training for coping with stressors, and (g) sys-
tematic desensitization for specific phobia. Probably efficacious treatments include two treatments
for PTSD (exposure treatment and stress inoculation training), as well as other treatments for PD,
GAD, specific phobia, and OCD.
Although the empirically supported therapies for anxiety disorders share a cognitive-behavioral
approach, the implementation of cognitive-behavioral techniques differs depending on the disor-
der. This section of the chapter will outline the general techniques of cognitive-behavioral therapy,
while integrating brief descriptions of the ways the techniques would be used when treating a
particular anxiety disorder.
Most cognitive-behavioral therapies contain a significant psychoeducational component. Therapists
obtain descriptions of patients’ problems and conceptualize them within a cognitive-behavioral
framework. Therapists often share their understanding of the nature and purpose of anxiety and
break anxiety into components that will be important for treatment, such as thoughts, sensations,
and behaviors. Throughout this process, it is important for therapists to solicit the opinions and
interpretations of their patients, because the goal is to arrive at a common understanding of the
anxiety problem that will underlie the remainder of treatment.
The psychoeducational component differs depending on which anxiety disorder is the focus of
treatment. For instance, the clinician might spend more time explaining the physiological basis of
anxiety with a patient who has PD than with individuals who have other anxiety disorders. Because
patients with PD are very fearful about the implications of their physical symptoms, it is helpful to
explain the origins of their symptoms in the sympathetic nervous system, and to point out that
these symptoms are not harmful. On the other hand, individuals with OCD are frequently taught
about the paradoxical effects of thought suppression, whereas patients with phobias learn that
escape and avoidance of feared situations serve to maintain their fear.
It should be apparent that the content of the psychoeducational component of treatment varies
depending on the particular anxiety problem. The important common factor is that patients adopt
a new way of thinking about their problems that is more likely to lead to change. Explanation of
treatment strategies and providing a rationale for each of them also contribute to increasing the
patient’s understanding of and motivation for treatment.
The psychoeducational aspect of cognitive-behavioral therapy renders treatment relatively
“transparent” to patients, which allows them to be active participants in their own attempt to
change. Another aspect of cognitive-behavioral therapy that increases patient participation is
assignments completed outside of therapy sessions, sometimes called the homework of therapy.
Homework serves to apply and reinforce what the patient learns in sessions and allows the patient
to develop anxiety management skills to a much greater degree. It is unlikely that patients will be
able to master new ways of thinking and behaving without considerable practice between sessions,
and therefore most cognitive-behavioral therapists emphasize monitoring and other exercises as an
essential part of treatment. For homework, a patient with PTSD might be asked to write paragraphs
about his or her traumatic experience in order to facilitate processing of the traumatic material
(e.g., Calhoun & Resick, 1993). In contrast, a patient with a specific phobia might be required to
gradually confront feared situations of increasing difficulty over the course of treatment. Finally,
patients with GAD could be assigned exercises that help them identify and challenge their worri-
some thoughts. These assignments not only help to transfer the benefits of therapy from the
consulting room to the real world, but they also provide an ongoing indication of the patient’s
understanding of and commitment to treatment.
Techniques that are taught to patients during the course of anxiety treatment help them to
change maladaptive patterns of thinking and behavior. Changing thought patterns usually entails
teaching the patient the technique of cognitive restructuring. Patients must first learn to identify
the thoughts associated with their emotions, which is sometimes difficult because of the automatic
or habitual nature of anxious thinking. Once they are able to stop themselves in an anxious
moment and identify what their concerns are, patients can begin to alter their patterns of thinking.
Under certain circumstances, patients are taught to recognize specific types of distorted thinking
that are common during anxious episodes. These distorted ways of thinking include patterns such
as “all or nothing thinking,” “jumping to conclusions,” and “magnification” (Burns, 1999).
Challenging anxious thoughts also entails considering the evidence that supports and refutes
anxious thoughts, as well as evaluating the real impact and importance of feared outcomes. Patients
are taught to ask questions in response to their anxious thoughts and to introduce some logical
thinking into their emotional reasoning. Patients may ask themselves, “What evidence do I have
that ________ will happen?” or “How important is it really if _______ does happen?” Once they
answer these questions, they may be able to come up with a more balanced or rational way of think-
ing about the situation, which is reinforced the more the patient practices. Over time, introducing
more balanced thinking into anxiety-provoking situations serves to alleviate patients’ distress. The
goal of cognitive restructuring is for the patient to learn that his or her anxious assumptions are not
necessarily true, and that alternate ways of thinking may lead to less aversive emotional reactions.
Clinicians also incorporate behavioral exercises to promote cognitive change. For instance, while
focusing on changing patterns of thinking, patients are often asked to perform experiments to test
their anxious beliefs. When anticipating an anxiety-provoking situation, patients typically make
numerous predictions about negative and even disastrous outcomes. They can learn a great deal by
facing the situation and obtaining objective evidence that often completely contradicts their
anxious predictions. For example, patients with GAD often worry about turning in work that is not
perfect, which leads to extensive reviewing and reworking of projects. When anxious, they may
predict that imperfect work would lead to being chastised by their superiors or even being fired. To
test these beliefs, the patient might be asked to hand in a report that includes a misspelling or a
minor omission. The patient might find that small errors have little consequence and certainly do
not lead to catastrophe. These learning experiences may lead to less worry about task completion
and reinforce cognitive change.
The behavioral experiments used to help change maladaptive thought patterns resemble an
important behavioral approach called exposure. Situational exposure entails confronting a feared
situation and refraining from attempts to avoid the anxiety that is provoked. The content of expo-
sure varies depending on a patient’s presenting problem, but might include driving on a highway
(driving phobia), recounting a traumatic experience (PTSD), or asking a stranger for directions
(social phobia). In the case of PD, patients also undergo interoceptive exposure, which involves
deliberate provocation of the sensations that they fear (e.g., hyperventilating to induce shortness of
breath and dizziness). The common element of each form of exposure is that patients allow the
anxiety or fear process to take its natural course, without trying to avoid the emotion. This allows
patients to experience the process of habituation, in which anxiety diminishes over time as the situ-
ation becomes more familiar and the patient’s worst-feared consequences do not eventuate. Over
time, patients usually find that habituation occurs more quickly, and that their initial level of anxi-
ety is not as intense. Exposure must be practiced repeatedly in order to achieve its therapeutic
effects, so a significant portion of session time and homework may be devoted to such activities.
Exposure is a treatment strategy that counteracts the detrimental effects of avoidance, which is
associated to varying degrees with each anxiety disorder. Another behavioral component of many
anxiety disorders involves problematic behaviors, such as excessive cleaning in OCD or the “safety
behaviors” associated with PD. During cognitive-behavioral treatment, patients are helped to
decrease and eventually eliminate these problematic behaviors. Clinicians explain that such
behaviors, which are initially perceived as alleviating anxiety, actually maintain the anxiety problem
in the long term. Patients experiment with phasing out problematic behaviors (e.g., decreasing
lock-checking from 10 times a day to 3 times a day) or make a commitment to eliminating them
altogether from the start of treatment (e.g., the response prevention component of intensive
treatment for OCD).
The treatment components described above comprise the basic strategies of most cognitive-
behavioral therapies for anxiety disorders. A multitude of other techniques may be incorporated
depending on the specific problem. Some examples include relaxation training, problem solving,
time management, and social skills training. For more detailed information about the procedures
for treating a particular anxiety problem, readers are referred to disorder-specific treatment manuals,
which are listed in Suggested Reading.
Practical Issues Related to the Administration of Treatment

Psychologists, psychiatrists, licensed social workers, and clinicians under their supervision typically
conduct cognitive-behavioral treatment for anxiety. Individuals who administer this form of
therapy should have had extensive training in both general therapeutic techniques as well as specific
treatment protocols. This training may occur in the form of some combination of supervision by
an experienced clinician, formal education, or workshops led by reputable experts in the field.
Mental health professionals who have not received formal training in a specific form of therapy
should seek appropriate supervision before and during their first attempts to utilize cognitive-
behavioral techniques.
Primary care clinicians have important roles to play in the delivery of mental health treatment,
even though most patients are referred to a mental health professional when psychosocial treatment
is indicated. As noted above, primary care settings are often the first point of contact for anxious
patients, and therefore the early phases of assessment will occur there. Primary care clinicians can
greatly improve their patients’ chances of receiving effective treatment by familiarizing themselves
with community resources for anxiety treatment. Unfortunately, many patients with anxiety disor-
ders receive suboptimal treatment because they are referred to “generalist” psychotherapists who
are not trained in the empirically supported treatments for anxiety disorders. Primary care physi-
cians should make efforts to determine a therapist’s specialties and approach to treatment before
making a referral. Given the research literature, it is recommended that referrals be provided to
cognitive-behaviorally oriented clinicians who have substantial experience with anxiety disorders.
If patients opt to search for a therapist on their own, the primary care clinician can educate the
patient about which treatment approaches have been found effective so that the patient is an
informed consumer.
A recent development that may streamline the referral process for primary care clinicians is the
integration of mental health services into some primary care settings (Dea, 2000; Nickels &
McIntyre, 1996; Price, Beck, Nimmer, & Bensen, 2000). The presence of qualified mental health
professionals in the primary care setting would simplify the referral process greatly and might also
increase the likelihood of patients pursuing more specialized treatment for their anxiety difficulties.
Integration of primary and mental health care could also facilitate communication among provid-
ers and produce medical cost offsets (Dea, 2000; Katon et al., 2002). Initial studies of integrated care
for PD and GAD suggest that this form of treatment produces better outcomes for patients, along
with the possibility of reduced health-care costs (Katon et al., 2002; Price et al., 2000).
Once the patient finds a suitable therapist for anxiety treatment, the primary care clinician may
continue to support the patient by collaborating with the mental health clinician. Communication
between treatment providers is strongly recommended, particularly if the primary care clinician is
prescribing medication for anxiety. Primary care clinicians can facilitate mental health treatment by
scheduling follow-up appointments to check on the patient’s progress. This conveys to patients that
treatment for anxiety is important, and it may enhance their motivation to comply with recom-
mendations. Because overcoming anxiety often involves difficult tasks (e.g., facing feared situa-
tions), additional support for the patient’s efforts is always helpful and may even improve
compliance. Meeting with the patient after the referral process is complete also provides a forum
for the patient to discuss other options if he or she is dissatisfied with the treatment.
The role of the primary care clinician may be expanded under some circumstances. For instance,
clinicians who are prescribing medications for anxiety will have more frequent contact with the
patient’s psychotherapist to coordinate care. In some cases, patients want to decrease or stop medi-
cation use as they acquire new skills for managing anxiety. Primary care clinicians will be involved
in advising them of an appropriate taper schedule and informing them about any expected with-
drawal effects. Primary care physicians can consult a recent chapter by Spiegel, Wiegel, Baker, and
Greene (2000) for more detailed guidelines on the pharmacological treatment of anxiety disorders.
Primary care clinicians may also play an important role for patients whose anxious behaviors
include seeking reassurance from their doctors (e.g., the patient with PD who calls his or her doctor
every time a heart palpitation occurs). Providers of psychological treatment should enlist primary
care clinicians to help decrease these safety behaviors and to selectively reinforce appropriate use of
primary care resources.
The availability of self-directed treatment manuals for many anxiety disorders introduces the
possibility that primary care clinicians will play a more direct role in anxiety treatments. As
mentioned above, patients with milder anxiety problems may benefit from simple psychoeducation
and manuals describing exercises they can complete on their own. Self-directed treatment manuals
exist for virtually every anxiety disorder, and many patients may choose this form of treatment for
its flexibility and convenience (see Suggested Reading/Websites for Anxiety on p. 107). In cases
where patients are attempting self-help, primary care clinicians should make follow-up meetings
can even greater priority. These meetings can consist of helping to maintain the patient’s focus on
the program and troubleshooting any difficulties that arise.
Prevention
In addition to treatment options for anxiety disorders, prevention or early intervention in primary
care may stop progression and the development of complications and subsequent relapses.
Prevention efforts may include empathic responses to major life events, provision of social support,
identification of at-risk individuals, and the promotion of mental health through self-help manuals
and education (Murray & Jenkins, 1998). Psychoeducation, which is a key component of cognitive-
behavioral treatment, may be particularly beneficial for preventing the development of an anxiety
disorder in individuals who exhibit subclinical anxiety symptoms. Patients presenting to primary
care settings with physical symptoms having no underlying medical condition, or are in excess of a
medical condition, should be educated about the nature of anxiety and the potential
misinterpretation of symptoms of anxiety. This psychoeducation may prevent the development of a
clinical anxiety disorder and its concomitant emotional, financial, and social costs.
Case Example
Ms. A is a 36-year-old, married, African-American female who works as a school teacher. In a
12-month period she had several appointments with her primary care physician, Dr. B. Ms. A was
diagnosed with asthma and hypertension; both conditions are well-controlled with medication.
However, Ms. A reported symptoms of nausea, intestinal distress, and hot flushes at her first two
primary care visits of the year. Although they never fully resolve her symptoms, Ms. A stated that
she “never goes anywhere” without numerous over-the-counter medications for nausea and intesti-
nal distress. At her third visit, Ms. A was given a referral to a gastroenterologist for a full evaluation
of her symptoms. The results of testing for gastrointestinal diseases were negative.
For her fourth appointment with Dr. B, Ms. A was asked to arrive 20 minutes early. In the
waiting room, she completed the QPD on a hand-held computer. A nurse printed out the QPD
diagnostic summary report and placed it in Ms. A’s chart for Dr. B’s review. The QPD report sug-
gested that Ms. A could be suffering from both PD and GAD. She had endorsed unexpected attacks
characterized by chest discomfort, shortness of breath, stomach distress, hot flushes, and feelings of
unreality. Ms. A reported that she feared she would lose control during these attacks, and that she
was very worried about having more of them. In addition, Ms. A had endorsed excessive worry
about several different areas of her life. She reported that the worry was hard to control and that she
had associated symptoms of restlessness, irritability, and muscle tension.
In the consultation room, Ms. A spoke about her continued problems with nausea and intestinal
discomfort. Dr. B asked if she would be willing to discuss the results of the QPD in order to better
understand her symptoms. Ms. A agreed to this plan and acknowledged that she had been feeling
very worried about both her physical symptoms and other areas of her life (e.g., work, finances, her
marriage). Ms. A indicated that she frequently felt “keyed up” and that she became especially upset
when she had sudden nausea, hot flashes, and other symptoms that made her feel like she was going
to “lose it.” She reported that she was beginning to refrain from taking long car trips and from
going to church because she did not want to be “trapped anywhere for too long” or to embarrass
herself by having to exit a situation suddenly.
Ms. A and her physician talked about the possibility that her symptoms might be related to anx-
iety. Her physician provided educational pamphlets on PD and GAD. Ms. A glanced at the
pamphlets and stated, “This looks like me.” When asked why she had not disclosed her anxiety
symptoms before, Ms. A replied that she had only discussed her somatic symptoms because she did
not think it was appropriate to discuss “mental problems” with her primary care doctor. Her physi-
cian replied that disclosing emotional symptoms was appropriate and in fact helped to determine
the best course of treatment.
Ms. A discussed several different treatment options with her doctor including pharmacother-
apy, referral to a cognitive-behavioral therapist, and self-directed therapy. Dr. B reviewed the poten-
tial benefits and side effects of selective serotonin reuptake inhibitors (SSRIs), and Ms. A decided
that she would try a low dose of one of these medications. She was concerned about side effects,
but also felt that medication would be more manageable for her than regular psychotherapy
appointments.
Ms. A also expressed interest in reading more about cognitive-behavioral techniques for manag-
ing anxiety. Dr. B referred her to the client workbooks Mastery of Your Anxiety and Panic and
Mastery of Your Anxiety and Worry (see Suggested Reading/Websites for Anxiety on p. 107). At her
follow-up appointment 1 month later, Ms. A reported that her anxiety and physical symptoms had
improved. She noted that simply learning more about anxiety and its physical manifestations had
been helpful, and seemed to prevent her panic symptoms from escalating. Ms. A also thought that
improvement in her anxiety symptoms had reduced the frequency and intensity of her asthma
attacks and gastrointestinal problems. She reported using her inhaler and her over-the-counter
stomach medications less frequently.
Ms. A had attempted some of the cognitive-behavioral strategies such as cognitive restructuring
and exposure to feared situations (e.g., she had resumed going to church). However, she was unsure
about trying the interoceptive exposure practices because of her other medical issues. Dr. B
reassured her that she could perform most of the symptom-induction exercises, but offered a few
modifications based on Ms. A’s history of asthma (Feldman, Giardino, & Lehrer, 2000). Ms. A
planned to try other techniques in the workbook, and also decided to increase her SSRI to a thera-
peutic dose.
Summary
Individuals with anxiety disorders frequently seek treatment from primary care clinicians, and
indeed may overutilize primary care resources. Inefficient treatment of anxiety disorders results in
strain on the primary care setting, as well as prolonged distress and life interference for the patient.
Efficacious treatments now exist for all the major anxiety disorders, and with adequate assessment
and treatment most patients whose problems are anxiety related can attain substantial alleviation of
symptoms and improvement in overall functioning. There are a number of tools that can help the
primary care clinician discern whether a patient’s problems are due to an anxiety disorder. Possible
screening questions, self-report inventories, and comprehensive screens developed for primary care
settings were reviewed in this chapter. Primary care clinicians should also familiarize themselves
with treatments that have demonstrated efficacy for alleviating anxiety disorders, and should be
prepared to make referrals to appropriate specialists. The major techniques employed by cognitive-
behavioral therapists were summarized in this chapter for the benefit of primary care clinicians
who might offer different forms of support to patients attempting this type of treatment. With
improved recognition of anxiety disorders and increased referrals to appropriate treatment, the
impact of these prevalent disorders on both individual patients and overburdened primary care
facilities may be substantially reduced.
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Suggested Reading/Websites for Anxiety

Suggested Reading
Textbooks
The following textbooks provide theoretical perspectives and information regarding the assessment and treatment of anxiety.
Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). New York: Guilford
Press.
Clark, D. M., & Fairburn, C. G. (1997). Science and practice of cognitive behaviour therapy. Oxford, England: Oxford Univer-
sity Press.
Rapee, R. M., Wignall, M., Hudson, J. L., & Schneier, C. A. (2000). Treating anxious children and adolescents. An evidence-
based approach. Oakland, CA: New Harbinger Publications.
Self-Directed Therapy Manuals

The texts below can be utilized by clients for self-directed therapy. Most of these workbooks have companion therapist
guides.
Antony, M. M., Craske, M. G., & Barlow, D. H. (1995). Mastery of your specific phobia: Client workbook. San Antonio, TX:
Psychological Corporation.
Antony, M. M., & Swinson, R. P. (2000). The shyness and social anxiety workbook: Proven techniques for overcoming your fears.
Oakland, CA: New Harbinger Publications.
Barlow, D. H., & Craske, M. G. (2000). Mastery of your anxiety and panic: Client workbook (3rd ed.). San Antonio, TX:
Psychological Corporation.
Burns, D. D. (1999). The feeling good handbook. New York: Plume.
Craske, M. G., Barlow, D. H., & O’Leary, T. A. (1992). Mastery of your anxiety and worry. San Antonio, TX: Psychological
Corporation.
Foa, E. B., & Kozak, M. J. (1997). Mastery of obsessive-compulsive disorder. San Antonio, TX: Psychological Corporation.
Rapee, R. M., Spence, S. H., Cobham, V., & Wignall, M. (2000). Helping your anxious child: A step-by-step guide for parents.
Oakland, CA: New Harbinger Publications.
Websites for Anxiety

The following websites provide resources for practitioners and consumers.
Anxiety Disorders Association of America: includes professional referral listings, educational information, self-help tools,
and an online bookstore. Visit www.adaa.org
National Institute of Mental Health Website: provides fact sheets, references, press releases, and links to other resources. Visit
www.nimh.nih.gov/anxiety
Chapter 5
Suicide and Parasuicide Management in the
Primary Care Setting
ELIZABETH A. LILLIS AND ALAN E. FRUZZETTI
Suicidal people commonly present in integrated care settings, and primary care is often the only
point of contact with professionals for this population. Although comprehensive treatment of
suicidal patients is outside the scope of primary care settings, guidelines for assessment and brief
intervention are necessary for stabilization of these patients and to make appropriate referrals for
comprehensive treatment. This chapter provides a set of guidelines for how to assess and manage
suicidality and parasuicidality in an integrated care setting. Assessment includes not only identifying
suicide risk factors, but also differentiating between acutely and chronically suicidal individuals.
Further, given the challenging nature of working with highly emotionally dysregulated patients,
methods of reducing the suicidal patient’s emotional arousal will also be addressed. Then,
assessment and brief interventions can be integrated, which may reduce immediate risk and also
facilitate more accurate assessment. This, in turn, may make referrals and subsequent treatment
better matched and more effective. Specific steps in conducting a risk assessment and interventive
assessment will be addressed, and issues related to referring suicidal patients to appropriate
treatment will also be discussed.
Suicide is the 11th-leading cause of death in the United States, and the 8th-leading cause of
death among males (National Institute of Mental Health, 2001). There are an average of 84 reported
suicides per day, one every 17 minutes, or about 30,622 completed suicides per year (National
Institute of Mental Health, 2001; Westefeld et al., 2000). Of course, the total number of actual
deaths by suicide is likely higher; a substantial number of deaths that are likely suicides are officially
listed as “accidents.” For young adults between the ages of 15 and 24, suicide is the 3rd-leading
cause of death (National Institute of Mental Health, 2001). Every year, approximately 186,000
Americans are affected when a close friend or family member commits suicide (American Association
of Suicidology, 1998). Moreover, for every completed suicide, many times that number of people
engage in unsuccessful suicide attempts, make suicide plans, or are disturbed by suicidal thoughts.
Moreover, individuals who ultimately do kill themselves are two to three times more likely to have
had recent contact with primary care providers (PCPs) than with mental health providers (Luoma,
Martin, & Pearson, 2002). In fact, the primary care setting is the de facto setting for mental health
109
services for a large number of patients in the United States (Regier, Goldberg, & Taube, 1978).
Despite the high prevalence of suicidal behavior, there have been few advances in how to predict
suicide attempts, or how to discriminate between those with suicidal thoughts or plans who will
not act on them and those who will. Even though health-care professionals encounter suicidal
patients every day, suicide assessment remains unstandardized and effective prevention strategies elusive.
Accurately identifying those who will attempt suicide is extremely difficult because of the prob-
lems of base rates and false positives. That is, it is likely that 95% of the general population has
thoughts about suicide in their lifetime (Chiles & Strosahl, 1995). Chiles and Strosahl (1995) inves-
tigated suicidal ideation in the general population and found that 20% of those surveyed had at
least one episode of moderate to severe suicidal ideation (with a formed plan) over a 2-week time
period, and 20% had at least one episode of troublesome suicidal ideation (without a formed plan)
over a 2-week time period. Approximately 500,000 individuals are treated for attempted suicide
each year (U.S. Public Health Service, 1999). Thus, engaging in suicidal thoughts is extremely com-
mon in the general population, although completed suicide is extremely rare. Thus, suicidal
thoughts are poor predictors of suicide attempts and completion. This may also be considered a
problem of base rates: only one out of the thousands that engage in this behavior will end up com-
pleting suicide. Consequently, most indices of risk based on suicidal ideation alone result in very high
rates of false positives.
This chapter will serve several functions. It will primarily address the function and role of the
primary care provider in suicide assessment and response. We will discuss the distinctions between
acute versus chronic suicidal patients, and short-term versus long-term assessment and treatment
strategies. We will then highlight risk factors in different populations. Furthermore, we will provide
a rationale and overview for conducting a brief behavioral analysis and “interventive interview”
with suicidal and parasuicidal patients, which will serve as a core patient management strategy in
primary care settings in order to reduce risk, improve assessment, and facilitate appropriate
referrals when needed.
Models of Suicide
Many factors have been identified that statistically increase the risk of a suicide attempt. However,
these factors are found at high rates in individuals who do not commit suicide. Thus, it is clear that
some individuals will commit suicide and some will not, but the factors that discriminate between
these two groups are not clear.
Social learning theories have been proposed for suicidal behavior; for example, it has been
proposed that completed suicide is more common in societies where condemnation of suicide is
low (Lester, 1988). Durkheim (1951) hypothesized that this factor may account for the low suicide
rates among Catholic, Greek Orthodox, and Jewish populations. Linehan (1973) also investigated
sex differences in society. She proposed that if attempted suicide is seen as a “weak” or “feminine”
behavior, then men may be less likely to choose that alternative until emotional dysregulation leads
to more lethal attempts.
Suicide has also been theorized as a learned problem-solving technique (Carr, 1977; Chiles and
Strosahl, 1995; DeCatanzaro, 1981; Ferster, 1961; Linehan, 1993, 1999). This model posits that
suicidal acts are a learned means of alleviating painful internal states or aversive external problems.
Feelings such as sadness, anxiety, shame, guilt, or other intense negative emotions can be an
integral part of a suicidal crisis, as can an external event such as the loss of a loved one or a recent
divorce. Essentially, engaging in suicidal behavior might sometimes be effective, at least in the
immediate sense of escaping from suffering; other people might respond with increased attention
or soothing, or they may stop criticizing or aggressive acts. Privately, the patient is likely seeking
Suicide and Parasuicide Management in the Primary Care Setting • 111
relief from a difficult emotional state. The hypothesis is that the self-injurious and suicidal behavior
of a chronically suicidal individual is being reinforced. This is one premise of dialectical behavior
therapy (DBT), the only empirically supported therapy to date for treating chronically suicidal and
parasuicidal patients with borderline personality disorder (Linehan, 1993).
Demographics of Suicide
As noted earlier, most people have had or will have suicidal thoughts during their lifetime. About
40% of people have serious thoughts of suicide consistently for 2 or more weeks, 20% of these
people will form a plan, and ultimately, 1–2% of those who form a plan will carry through with the
plan and take their own life (Chiles & Strosahl, 1995). However, the magnitude of this problem has
not made predictions accurate or interventions successful. There are some epidemiological data
that identify subgroups of people who are at higher risk for suicide. However, these kinds of nomo-
thetic (group) data do not provide information regarding an individual’s risk for suicide. What is
known is that being human is itself an individual risk factor for suicidality. Available epidemiological
data are presented below. It is important to keep in mind that when an individual presents in the
clinic with suicidal thoughts, the following factors point to a level of risk but cannot replace an
idiographic assessment and do not predict patient response to intervention. Despite this, risk-factor
information is useful because it identifies individuals who are at higher risk to treatment providers.
These individuals require a lower threshold for aggressive intervention.
Social Risk Factors

Certain social factors influence suicide risk. In general, unmarried people (single, divorced,
widowed) commit suicide more than those who are married (Statham et al., 1998). This is espe-
cially true in the elderly population (McIntosh, Hubbard, & Santos, 1994). In a study of one
Maryland county linking state death records, Li (1995) reported that suicide rates of widowed men
were three times higher than that of married men. However, older widowed women showed no
increase in suicide rate as compared to older married women. Duberstein, Conwell, and Cox (1998)
found that widowed older individuals were at greater suicide risk within 4 years following the death
of a spouse. Being unemployed also accounts for a higher risk of suicide (Reinecke, 2000). Also, in
the case of the elderly, the suicide rate is known to increase after retirement (McIntosh, 1995).
Family Risk Factors

Family history also plays a role in suicidal behavior, and suicide tends to cluster in families. There
are at least two explanations for this risk. The first is social learning theory (Diekstra, 1973), which
states that suicidal behavior is a learned coping method and depends on suicidal behaviors in a
person’s existing repertoire. Modeling has been hypothesized to play a role in influencing an indi-
vidual’s suicidal behavior (Bandura, 1969). That is, if an individual observes suicidal behavior, this
individual can acquire those modeled responses him- or herself. Diekstra (1973) stated that suicidal
behavior is acquired through socialization and that family and friends provide both the motives for
suicidal behavior and the expectations about the outcome of suicidal behavior. This and other sim-
ilar findings (Perlin & Schmidt, 1975) suggest that suicidal behavior is not simply mimicked by the
observer, but that some sort of cognitive appraisal of the behavior occurs and then mediates the
response. However, a 1985 study demonstrated that individuals recently hospitalized for a suicide
attempt reported fewer suicidal models than did suicidal ideators, nonsuicidal psychiatric patients,
and medical controls (Chiles, Strosahl, McMurtray, & Linehan, 1985). Other studies looking at
suicidal modeling effects have found the opposite: attempters often have relatives who have engaged
in suicidal behavior (Maxmen & Tucker, 1973; Murphy & Wetzel, 1982). Thus, the findings are
mixed, and it is unclear what impact modeling has on suicidal behavior.
Genetics has been proposed as a second explanation for familial risk of suicide. Some studies of
monozygotic and dizygotic twins have found that the clustering may represent genetic loading for
those psychiatric disorders associated with suicide (but not for suicide per se). Data are mixed with
respect to the impact of family environmental factors on suicide (Chiles & Strosahl, 1995; Roy, Segal,
Centerwall, & Robinette, 1991; Keitner et al., 1987). For example, a study by Statham et al. (1998)
using monozygotic and dizygotic twins supported the view that suicidal loss of a close relative may
trigger suicide in other family members only if they share the relevant genetic predispositions.
Given these two explanations, it can further be hypothesized that familial risk factors are
mediated through shared biological vulnerability and a shared environment (Moscicki, 1997).
Whether environmental, genetic, or both, a family history of psychopathology or suicidal behavior
is an essential part of risk assessment of the suicidal individual.
Age
Suicidal risk increases with age, with the highest risk being in elderly males (Pearson, 2000).
The overall suicide rate among those over 65 is approximately 19 per 100,000, and approximately
23 per 100,000 for those between 75 and 84 (Kochanek & Hudson, 1995). Given the varying pro-
cesses of completing death certificates for the elderly, this may even be an underestimate for this
population. Death certificates, depending on the state, may be completed by any number of people
including an appointed layman, lawyer, sheriff, mortician, general practitioner, or a forensic
pathologist (Pearson, 2000). For isolated elderly patients whose death certificate is being handled by
unfamiliar people, a suicide attempt such as a medication overdose or a fall could be mistaken for
an accident or as resulting from dementia. Another consideration for the elderly is that even though
the death rate by suicide is higher than for all other age groups, it is not the most common form of
death. Heart disease, malignancies, and cerebrovascular diseases are more common forms of death
than suicide in this cohort (Morgan, 1989). Therefore, treatment providers working with the elderly
may overlook suicide risk while assessing physical ailments, perhaps leading to suicides that could
have been prevented or suicides that are believed to have resulted from accidental overdoses.
Chronic Pain and Medical Illness

Individuals suffering from chronically painful conditions such as migraine headaches (Breslau,
Davis, & Andreski, 1991), low back pain (Penttinen, 1995), and cancer (Breitbart, 1993) have
elevated rates of suicidal ideation and attempts. Depression in pain patients has been associated
with greater pain intensity and pain-related disability (Haythornthwaite, Sieber, & Kerns, 1991),
higher levels of catastrophizing (Geisser, Robinson, Keefe, & Weiner, 1994), and lower levels of
social support (Kerns, Haythornthwaite, Southwick, & Giller, 1990), all of which may contribute to
increased suicidal ideation.
The relationship between chronic pain and illness is not a simple one (Breitbart, 1993). Studies
suggest that patients with chronic pain are at increased risk for suicidal intent, possibly due to ele-
vated rates of depression (Fisher, Haythornthwaite, Heinberg, Clark, & Reed, 2001). For example,
in a study of cancer patients, suicidal ideation was not related to the intensity of the cancer, but
rather to the degree of depression (Saltzberg et al., 1989). Among individuals with chronically
painful conditions, there is a shortage of studies that control for depressive symptomotology
(Fisher et al., 2001), making conclusions about increased risk with this population difficult.
However, it can be concluded that individuals with chronic pain compounded with depression are
at greater risk for suicidal ideation and attempts.
Psychological Risk Factors

Suicidality is not exclusive to any one mental disorder. Studies demonstrate that many different
diagnoses include the symptomotology of suicidality, with suicide rates within these diagnoses
ranging from 5–15% (Chiles & Strosahl, 1995). However, suicide rates are much higher in the
psychiatric population than in the general population. The base rate of suicide in the general
population is approximately 12 per 100,000 versus 60 per 100,000 in the psychiatric population
(Hilliard, 1995; Murphy, 1984; Tanney, 1992). A large retrospective study with veterans showed
completed suicides were most often associated with depression (present in 50% of completed
suicides), alcohol and drug abuse (present in about 20–25%), and schizophrenia (present in about
10%) (Pokorny, 1992). Inskip, Harris, and Barraclough (1998) have presented a more recent risk
estimate of 6% for affective disorders, 7% for alcohol dependence, and 4% for schizophrenia.
Similarly, bipolar disorder has also been demonstrated to be associated with suicidality, particularly
bipolar II. In fact, a history of suicide attempts was highest, as was death by suicide, among bipolar
II patients over bipolar I, or even those with unipolar depression (Dunner, 1998).
Some clarification is needed regarding suicide prevalence data. Although the correlation
between depression and suicide is high, the correlation is not as simple as it is often described. For
example, although half of those who have completed suicide have had a diagnosable depressive
disorder, the disorder itself is not a valid predictor of suicidality because of its significantly higher
base rate, especially in primary care settings. In fact, the vast majority of depressed patients never
engage in suicidal behaviors. Although the base rates of suicide in the United States are 12 per
100,000 people (Hilliard, 1995; Murphy, 1984; Tanney, 1992), it is estimated that between 230 and
566 per 100,000 of the population have a depressive disorder (Clark, Young, Scheftner, Fawcett, &
Fogg, 1987; Fremouw, de Perczel, & Ellis, 1990). Thus, although a very substantial portion of sui-
cidal patients are depressed, the reverse is not true. Thus, it is faulty to infer that depression per se is
a more substantial risk factor than a host of other diagnoses that similarly carry high risk, such as
schizophrenia, substance dependence, and borderline personality disorder.
Also relevant are other factors that potentiate suicide risk in those individuals with affective
disorders, schizophrenia, and alcohol dependence. Just having the disorder does not necessarily
increase risk, but having the disorder in addition to other environmental influences seems
to increase risk. These factors will be discussed along with the disorders themselves.
Psychiatric Disorders
As previously stated, depression is the most common diagnosis associated with suicide. Again, this
is not to say that most depressed individuals are suicidal, but that suicidal individuals also tend to
have diagnoses of depression. A study by Fawcett, Scheftner, Clark, and Hedeker (1987) indicated
that severe anhedonia, global insomnia, diminished concentration, severe anxiety, panic attacks,
obsessive-compulsive features, and acute use of alcohol significantly increased acute risk of suicide
within 6–12 months of the reference diagnosis of depression. Short-term risk in this sample
increased if (1) the current episode of depression was one of three or fewer lifetime episodes; (2) the
individual had no children under age 18 in the home; and (3) she or he also demonstrated a current
episode of cyclic affective disorder (such as bipolar I or II).
Suicide among those diagnosed with schizophrenia tends to occur earlier in the lifespan,
with the modal age of suicide in early adulthood (relatively early in the course of the disorder).
Follow-up studies have estimated that approximately 10% of individuals with schizophrenia die by
suicide, which is the main cause of death among these patients (Andreasen, 2000). Typically,
schizophrenic patients who commit suicide are white males who have never married and who have
not experienced a full recovery after the first few psychotic episodes. The risk is even higher for
those who are better educated and have higher expectations for themselves, as well as for those who
had higher premorbid functioning (Cohen, Test, & Brown, 1990). Relative to acute risk, Peuskens
et al. (1997) found that concurrent depression increased the prevalence of schizophrenic suicide.
For young, white schizophrenic males who have higher levels of intelligence, severe co-morbid
depression is a short-term risk factor that should be assessed.
Survivors of highly traumatic isolated events or chronic traumatization are at high risk for a
variety of psychiatric syndromes, including posttraumatic stress disorder (PTSD); dissociative
disorders; severe personality disorders; and substance abuse, depression, and eating disorders (Chu,
1999). Many trauma patients have attempted suicide or engaged in parasuicidal behavior, and
many have chronic suicidal ideation and impulses. Traumatic events that often result in these
symptomologies are wartime combat, physical or sexual assault, psychological terror, accidents, and
natural disasters (Chu, 1999). Not surprisingly, borderline personality disorder (BPD) patients
frequently have some form of trauma in their histories, most often childhood physical or sexual
abuse (Linehan, 1993).
PTSD has been shown to increase suicide risk. For example, combat veterans are seven times
more likely than the general population to commit suicide (Bullman & Kang, 1994). These
researchers also demonstrated that combat veterans with PTSD and another concurrent psychiatric
diagnosis were 10 times more likely to commit suicide than those without PTSD. Substance abuse
and depression were also highly correlated with completed suicides and PTSD.
Duberstein and Conwell (1997) estimated that 30–40% of individuals who complete suicide
have an Axis II personality disorder. One of the most frequent personality disorders associated with
elevated suicide risk is BPD. In a study of BPD inpatients followed from 10–23 years after discharge
(Stone, 1989), patients meeting all eight DSM-III criteria for BPD at admission had a suicide rate of
36% compared with a rate of 7% for those who met five to seven of the criteria. The same study
showed that BPD individuals who had a history of self-injury had double the suicide rates of those
without previous self-injury; 70% of BPD patients have a history of at least one act of self-injurious
behavior (Cowdry, Pickar, & Davies, 1985), thus highlighting the difficulty in accurately identifying
the approximately 9% of BPD patients that will complete suicide (Stone, 1989).
These are complicated data, however, because the co-morbidity of BPD with affective disorders
or substance abuse is high (Kleespies & Dettmer, 2000). Tanney (1992) found that in several studies
that examined serious suicide attempts (those attempters with clear intent to die, yet their method
was unsuccessful) there was a co-morbid affective or substance abuse disorder diagnosed along
with BPD. Another study demonstrated that 48% of substance abuse suicide completers also met
the criteria for borderline personality disorder (Murphy & Robins, 1967). Thus, individuals with
BPD and multiple Axis I disorders constitute a high-risk group for suicide.
Individuals with antisocial personality disorder also have a high rate of suicidal behavior, espe-
cially in adolescents (Hawton, 1986; Shaffer, 1974). Antisocial symptoms (e.g., bullying, stealing)
have been shown to be just as common as emotional symptoms (e.g., depression) in suicidal
adolescents (Shaffer, 1974). In one study, 45% of adolescents diagnosed with conduct or substance
abuse and depressive disorders made suicide attempts, compared with only 22% of adolescents with
depressive disorders alone and 10% of adolescents with no depressive disorders (Kovacs, Goldston,
& Gatsonis, 1993). Again, Axis II co-morbidity plays an important role when assessing for suicidal
behavior in those individuals diagnosed with an Axis I disorder.
It has also been proposed that risks associated with certain psychiatric diagnoses vary across the
lifespan. In a study by Conwell, Duberstein, Cox, and Hermann (1996) involving 141 suicide
completers, it was found that those in middle age were more likely to have co-morbid affective and
substance abuse disorders, while elderly suicide completers were more likely to have late
onset unipolar depression. In an earlier study by Dorpat and Ripley (1960), it was reported that
for suicide completers under 40 years of age, schizophrenia was the most common diagnosis; for
ages 40–60, alcoholism was the most common diagnosis; and for those over 60, depression with
psychotic features was the most common diagnosis.
Individuals having any of the mentioned psychiatric diagnoses have a higher risk of completing
suicide within 2 years of the patient’s hospitalization for a suicide attempt (Davis, Gunderson, &
Myers, 1999). For those individuals diagnosed with BPD, this risk is elevated for 5 years after the
hospitalization. A history of multiple hospitalizations has also been associated with a higher rate
of completed suicides (Kullgren, Renberg, & Jacobson, 1986). Therefore, assessing for the client’s
history of psychiatric hospitalizations, perhaps reflecting on instability and severity, is crucial in
determining greater risk for completed suicide.
Alcohol and Substance Abuse

In a study of alcohol intake and premature death, it has been reported that for those who consume
six or more drinks daily, there is a sixfold increase in suicide risk relative to nondrinkers (Klatsky &
Armstrong, 1993). Murphy and Robins (1967) found that 48% of alcoholics who completed suicide
had experienced the loss of an important relationship within 1 year of their suicides, while only
15% of the depressed suicide cases had comparable losses. Duberstein, Conwell, and Caine (1994)
extended these studies to include not only losses, but also interpersonal conflicts. That is, recent
conflicts with spouses or close friends increased the risk of suicide. It appears, in summary,
that interpersonal disruption is a large risk factor for suicidal vulnerability in alcoholics. Further,
the alcoholic patient is typically in an active period of drinking when he or she commits suicide
(Conwell et al., 1996).
Those who abuse other drugs are also at elevated suicidal risk. In a study by Marzuk, Tardiff,
Leon, and Morgan (1992), one in five individuals under the age of 60 who committed suicide had
used cocaine in the days prior to their deaths. Fifty percent of the cocaine users also used alcohol.
In studies investigating alcohol abuse alone, suicides tended to occur in middle age, while polysub-
stance abuse and solely drug suicides tend to occur earlier in life (Kleespies & Dettmer, 2000; Rich,
Sherman, & Fowler, 1989), with the mean age at suicide for alcoholics being 50 and the mean age at
suicide for polysubstance abusers being 31 (Porsteinsson et al. 1997).
Thus, psychiatric diagnoses, and in particular multiple co-morbid diagnoses, increase the risk of
suicide. Depression, substance abuse, and schizophrenia, as well as the relevant Axis II diagnoses
should be assessed when determining risk.
Differentiating Between the Suicidal and Parasuicidal Patient

In general, acutely suicidal individuals have not frequently engaged in suicidal or parasuicidal acts
previously and have recently suffered an extremely difficult event or loss, or an exacerbation of an
ongoing stressor. In contrast, chronically suicidal individuals typically have a history of suicidal and
parasuicidal activities, have had multiple treatments, and likely have been hospitalized in the past
for this behavior. For many reasons, quite different treatment protocols may be indicated for these
two subtypes of suicidal patients, so accurate assessment is needed to make an appropriate referral.
Treating the chronically suicidal patient as though he or she is not chronically suicidal could exacer-
bate suicidality or perpetuate chronicity, just as treating the first-time, acutely suicidal patient as
chronically suicidal could present unnecessary risks.
Discriminating between suicidal and parasuicidal (chronically suicidal and self-injurious)
patients is an important distinction to make owing to its implications for treatment. Certain kinds
of data help make this distinction. For example, the chronically suicidal patient often engages in
parasuicidal behaviors that distinguish them from acutely suicidal patients. The word “parasuicide”
was first defined by Kreitman (1977) to mean nonfatal, self-injurious behavior with clear intent to
cause bodily harm or death. This could be self-injurious behavior resulting in tissue damage or
other life-threatening bodily harm, or ingesting substances in amounts greater than the prescribed
dose in order to cause harm or death. Thus, the chronically suicidal, or parasuicidal, patient often
presents with a distinctive history of self-injury that is not characteristic of a patient who is experi-
encing an acute and limited period of suicidality. By recognizing these risk factors early on, proper
treatment can be expedited while circumventing unnecessary assessment.
Certain demographic factors may also be relevant in discriminating between the acutely and
chronically suicidal individual. For example, being female increases the risk of parasuicide
and decreases the risk of suicide (Linehan, 1993). In particular, meeting the criteria for BPD, which
is diagnosed more significantly in females than in males (Grilo, Becker, Fehon, & Walker, 1996),
increases the risk for parasuicidal acts. Women are more likely to use overdosing or poisoning, cut-
ting, burning, and other harmful acts with low risk of fatality. Males, on the other hand, complete
suicide more often than females, but are at a lower risk for parasuicide than females. The methods
typically used by males involve hanging or firearms (Canetto & Lester, 1995). Thus, though
BPD per se is a risk factor for suicide, males are generally more likely to complete suicide than
females. For primary care purposes, a female with a parasuicidal history is generally at lower risk
for a lethal suicide attempt than a male, whereas a male is typically considered at higher risk for a
lethal attempt with or without a parasuicidal history. In general, women attempt suicide more often
and men complete suicide more often (Fremouw et al., 1990).
Assessing affect also aids in distinguishing the chronically and acutely suicidal. Both acutely and
chronically suicidal patients may be depressed at the time of the act of parasuicide or suicide,
but nonchronic, acutely suicidal patients generally have a more “numb” depression, whereas the
chronically suicidal and parasuicidal is typically more angry or has other intense emotions
(e.g., shame). That is, the acutely suicidal patient appears more apathetic than openly hostile or
upset. Therefore, it is crucial to attend to affect with chronically suicidal patients (Linehan, 1993,
1999). If the care provider sees the patient becoming more depressed and apathetic over the course
of assessment, this may indicate an exacerbation of risk for a suicide attempt.
Assessing for risk factors is only the first step in understanding suicidal risk and cannot replace
an individual assessment in guiding assessment strategies and treatment plans. The following
sections will discuss two useful, comprehensive assessment options available in primary care and
how and when to use each one. The epidemiological information discussed above provides the
backdrop for individualized assessment, and we will return to it as we consider intervention and
treatment options. There are also some clinical issues that arise when dealing with such a high-risk
population, which are important for effective assessment and treatment planning.
Considerations for Assessment

Many primary care physicians understandably believe it is difficult (if not impossible) to conduct a
sufficiently effective suicide assessment to make an accurate referral or intervention in the less-
than-10-minute average time they have with each patient. However, a caring and thorough suicidal
assessment can often be reasonably brief as well as fit to be integrated into the treatment or inter-
vention procedure. To start with, establishing an accurate patient history via suicide self-report
questionnaires and communicating with other mental health professionals can be completed before
a crisis. This, along with routine diagnostic screening for mental disorders, can prevent suicidal
behavior on the front end by facilitating appropriate treatment referrals. Because between 50 and
90% of suicidal individuals meet the criteria for one or more psychiatric disorders, (Chiles &
Strosahl, 1995) these patients can be monitored for suicidality (and assessed on other dimensions)
more closely once they are screened. It is imperative that the primary health-care practitioner has
the patient’s mental health history data on hand (i.e., not just kept in a separate mental health facil-
ity). Having the information in multiple locales is fine, but it is important that the primary care
physician has ready access to the mental health history of his or her patients.
There are several indications that a particular patient may need to be assessed for suicidality.
The first is when the patient him- or herself reports feeling suicidal. The second is when there is
known parasuicidal or suicidal behavior in the patient’s history; this behavior should be assessed at
fixed intervals or during routine care. The third is if there are any indications of recent parasuicidal
behaviors (e.g., cuts, burns). The fourth is when the patient’s affect seems different from his or her
usual level of emotion, or when any of the aforementioned demographic or psychological factors
are present. Fifth is if the patient seems depressed, anxious, or numb. If any of these criteria are
met, a Beck Depression Inventory II (BDI-II; Beck, Steer, & Brown, 1996) can be given to the
patient as a brief screening device. If the answer to question 9 (Suicidal Thoughts or Wishes) is a 2
“I would like to kill myself ” or a 3 “I would kill myself if I had the chance,” further assessment is
necessary. The BDI-II takes only about 5 minutes for the patient to complete and has the benefit of
also measuring general psychological distress (Beck, Steer, & Garbin, 1988). Of course, the primary
care provider can also simply ask the patient if he or she feeling suicidal.
As mentioned earlier, there are two types of suicide assessment: risk assessment and treatment-
oriented (interventive) assessment. An empathic assessment of history and risk can be the first step
in any treatment for the suicidal patient, but treatment-oriented assessment capitalizes on this
approach by focusing time and resources efficiently when presented with a suicidal individual.
Available resources (time and staff) will determine which type of assessment is employed in any
given primary care setting. Both of these assessment approaches will now be discussed in more detail.
Risk Assessment
Risk assessment is primarily an assessment of short-term risk of imminent suicide, which is also
informed by longer-term risk factors. The goal of risk assessment traditionally has been to deter-
mine whether to hospitalize a patient. High-risk patients are hospitalized, and low-risk patients are
sent home, often with a referral to a mental health practitioner. Risk assessment can generally be
conducted by a wide range of staff and may require less time than an interventive assessment. Given
the current state of many managed health-care systems, it is important to note how system issues
affect the risk assessment and subsequent hospitalization of suicidal patients.
Feldman and Finguerra (2001) discuss several advantages and disadvantages of the managed care
system in terms of immediate response to suicidal patients. An advantage is that a managed
care, system is likely to contract with a wide spectrum of services for its members. They may
include partial hospitalization programs, acute residential treatment centers, crisis centers, respite
care, shelters, outpatient clinics, and many others. Effective managed care will have an advanced tri-
age system to place patients in the most appropriate setting. Also, the larger and better the system of
care, the more likely specialists will be available to manage crises, such as family therapists, behavior
therapists, addiction specialists, crisis teams, and so forth. Large systems also dilute responsibility
for the suicidal patient, reducing the burden for practitioners. Finally, record keeping in an efficient
system makes it easy to look up a patient’s previous crisis history.
Disadvantages to managed care are that in general, patients receive less treatment overall, are
discharged too early, or are placed in a less-intensive level of care than may be needed for safety
(Feldman & Finguerra, 2001). However, for the chronically suicidal individual, this could be benefi-
cial (they are more likely to be placed in a less-regressive outpatient setting). Given the issues
involved in hospitalization in the managed health-care era, risk assessment is crucial in determining
whether to refer a patient for inpatient treatment. Conducting risk assessment is a difficult task
because it is unstandardized, and risk assessment systems in general are not always applied reliably
to the individual patient. Most importantly, there are no valid algorithms for determining what
level of perceived risk necessitates hospitalization. Balancing costs, liability, and effective treatment
is the goal, but the various methods employed to achieve this balance have not yet received empiri-
cal support.
One problem with risk-prediction systems is that they have become highly statistical (Chiles &
Strosahl, 1995). Prediction equations have emerged that take into account key environmental,
personality, and historical characteristics of suicide. This has left us with many suicide prediction
instruments fundamentally unable to do anything but identify that a patient is in a higher risk
group. This is not the same thing as assessing short-term risk for the individual. The problem is
that the prediction systems identify groups of people with higher risk of suicide, but not individu-
als. For example, if it is known that on a certain questionnaire one item has been shown to be cor-
related with more completed suicides, and if a patient marks that answer, we know that he or she
might be in a group tending to have a higher rate of completed suicides. However, most members
of that group are not eventually going to attempt, much less complete, suicide. Knowledge of risk
factors per se still does not lead to effective treatment or referral, which must be determined on an
individual basis.
In order to conduct a risk assessment efficiently, focus should be placed on clinically relevant
information. Simply interviewing the client about every risk factor known will probably result in
the patients feeling misunderstood and taking an unnecessarily long time. In general, with excep-
tion to previous suicide attempts and a family history of suicide, the assessment should focus on the
current problem and suicidality. A more positive atmosphere is created by not linking this episode
to an entire lifetime of possibly misunderstood suffering.
The assessment of demographic variables, available means for completing suicide, intensity of
intent (urges), deterring factors, and a plan are all parts of risk assessment. The goal is to prevent
suicidal behavior. No treatment is conducted during a typical risk-assessment session, and in gen-
eral the two possible outcomes are: (1) the patient is deemed safe enough to leave from immediate
medical and psychological care (perhaps to return for mental health care at a later time) or (2)
hospitalization. Hospitalization plays a key role in risk assessment and should be considered
carefully. However, inpatient hospitalization is often unnecessary for safety, it incurs high costs, and
it may have (in some populations) iatrogenic effects. Hospitalization may also be overutilized to
limit primary care liability or because many providers have not learned alternative approaches.
Inpatient hospitalization has long been considered a standard of care for suicidal patients, and
given the legal and ethical responsibilities of a psychotherapist or other mental health-care
provider, it is sometimes necessary. However, one of the top five reasons for psychiatric malpractice
suits in the United States is unnecessary hospitalization (Hirsh & Lielbreidis, 1983). Therefore, it is
always preferable to obtain voluntary hospitalization; however, if the situation demands it, involun-
tary detention may be necessary. According to Beutler, Clarkin, & Bongar (2000):
Risk and retention are optimized if the patient is realistically informed about the probable
length and effectiveness of the treatment and has a clear understanding of the roles and
activities that are expected of them during the course of treatment (p. 182).
There are several points to keep in mind when deciding whether to hospitalize (Linehan, 1993,
1999). The first is the presence of a serious psychiatric state along with suicidal threats. For diag-
noses like schizophrenia, psychotic depressions, or severe affective disorders, hospitalization
may provide the around-the-clock management that only a hospital can provide. A second
consideration for hospitalization is if the patient has overwhelming acute problems and no social
support. The second consideration is whether the person lives in a home or social environment so
destructive that they cannot manage in it, and there are no other available refuges. A third consider-
ation is to monitor psychotropic medications when overdose risk is high. A fourth consideration
for hospitalization is when admissions are planned as a long-term treatment plan. This could
include conducting exposure treatment of posttraumatic stress in a safe environment and planning
a hospital stay when the primary therapist is on vacation, among other, nonacute therapeutic
reasons. The fifth consideration is whenever suicide risk outweighs the risk of inappropriate
hospitalization. This consideration is especially important in the hospitalization of chronically sui-
cidal individuals, for whom unnecessary hospitalization could be reinforcing suicidal behavior
(Linehan, 1993).
There are alternatives to hospitalization that provide necessary intensive treatment but without
the inpatient status. Partial hospitalization typically involves a day-treatment program for several
days or weeks and usually follows a period of inpatient hospitalization. For example, a suicidal
individual could spend several days in inpatient care and then go home with the regimen of
attending the partial hospitalization program every day for 8 hours for 2 weeks. Basically the
patient eats an evening meal and sleeps at home, and spends the rest of the time in treatment.
Acute residential treatment involves 24-hour care that is not typically held in a contained facility.
They are generally viewed as a kind of respite care and are less costly than inpatient admission.
Observation or holding beds allows extended assessment or 24-hour supervision while more triag-
ing options are entertained. Thus, there are more options than inpatient hospitalization that are
sometimes overlooked when a patient is deemed a danger to go home alone. It is important for
primary care providers to be aware of local resources for comprehensive mental health treatment
for suicidal patients.
Interventive Assessment
Risk assessment does not try to reduce present risk, only to assess it. An alternative approach to
assessment, what we call interventive assessment, focuses instead on risk reduction and generally
requires a more highly trained professional (many primary care providers could be trained to do
this) with sufficient time (up to 30 minutes) available. Interventive assessment is extremely useful
for the chronically suicidal patient in reducing both short-term and long-term risk, and it may
lower the incidence of unnecessary hospitalization or hospitalization that could have iatrogenic
effects. It is to interventive assessment that we will now turn. This approach to suicidal patients has
gained evidence to support its use, and with that have come respect and popularity in recent years
(Chiles & Strosahl, 1995; Linehan, 1993).
Chronic and multiproblem patients are typically good candidates for interventive assessment
because they often present in the clinic with parasuicidal self-injuries that are sometimes mistaken
for suicide attempts. The multiproblem patient is a patient who is regularly in crisis and for whom
suicidal behavior may be reinforced in multiple ways. BPD patients fit the profile of a multiproblem
patient. Their behavior is typically characterized by emotional reactivity or emotion dysregulation,
and interpersonal turmoil. Parasuicide or nonlethal suicide attempts (as well as possible lethal
suicide attempts) may function to alleviate misery temporarily in a variety of ways (Fruzzetti, 2002;
Linehan, 1993).
The goals of interventive assessment are to validate the patient’s emotional pain, teach accep-
tance of that pain, help the patient tolerate the pain, and help the patient make significant life
changes and reduce pain in the long term. Interventive assessment may be sufficient treatment for
some problems, or may simply help the PCP get an accurate assessment that facilitates making a
referral to an appropriate treatment program. The first step is to reframe the suicidality as an
implicit (or explicit) problem-solving technique that has been useful in the past (mostly as an
escape) but clearly has not solved the person’s life problems. Risk factors and information sur-
rounding the current episode are then gathered in a problem-solving context, with the participa-
tion and collaboration of the patient. The key to interventive assessment is that the suicidality is
not labeled as the problem, but rather the present triggers or current (temporary) life circum-
stances or recent problematic events are identified as the problem(s) to be ameliorated. Some
clients may break up with a partner or lose a job and manage their distress unproductively by
slashing tires or by aggressing against the person they feel is responsible for their pain, withdrawal,
or other ineffective acts. The multiproblem patient may feel so much emotional pain and have
such difficulty tolerating or ameliorating it that suicide seems the only solution. Thus, suicidal
behaviors may serve as an escape route from severe emotional pain, or paradoxically, may provide
relief from emotional pain. After identifying and validating the patient’s emotion, interventive
assessment focuses on the problem at hand, rather than on the ineffective ways in which the
patient has tried to manage it.
Reducing Emotional Arousal in Dysregulated Patients

The most common reason patients are difficult to manage is that there are high levels of emotional
arousal that can interfere with their normal capacity to think and problem solve (Fruzzetti, 2002;
Fruzzetti & Nilsonne, 2004; Linehan, 1993). Linehan (1993) describes this as emotion dysregulation.
What often happens in health-care settings is that patients become more dysregulated as a result of
the ways that the “system” responds to them, and this high arousal can result in crisis exacerbation.
For a sensitive and reactive suicidal patient, being told “you’ll just get another boyfriend/girlfriend”
may invalidate the person’s high levels of fear, anguish, or other emotion. Thus, by using brief
validating statements instead, and then helping patients reorient their attention, patient emotional
arousal can be reduced to a reasonable level, which in turn allows them to behave more effectively
(Fruzzetti & Nilsonne, 2004). Often, strategies to enhance emotion self-management should be
targeted before other problem-solving strategies to help patients de-escalate closer to their
baseline levels of emotional arousal; thus, interventions will be more effective and manageable for
care providers.
There are several reasons why reducing a patient’s emotional arousal can help bring about
positive consequences in the health-care setting (Fruzzetti & Nilsonne, 2004). These include:
1. Increases patient satisfaction with his or her health care. Satisfied patients are more willing to
cooperate with treatment goals. This could hopefully result in improved mood, more col-
laboration, and less suicidal behaviors. It is also important legally because, according to
Gutheil (1998), malpractice lawsuits often arise from a “malignant synergy” of bad outcomes
and bad feelings, not necessarily failure to provide appropriate treatment. Thus, by improv-
ing patient satisfaction, there will be less likelihood for malpractice lawsuits.
2. Increases the accuracy and relevance of information collected. An upset or agitated patient is
less likely to cognitively process in a way that allows for accurate assessment of information
necessary for effective problem solving.
3. Improves treatment and/or referral. More accurate assessment data will naturally lead to bet-
ter treatment and a better-matched referral for appropriate treatment.
4. Decreases agitation, resulting in fewer negative staff reactions and less staff burnout. The
high emotional arousal of suicidal patients can be frightening and frustrating to staff. By
decreasing the emotional arousal in patients, staff will be more motivated to help these
patients over a longer period of time.
5. Increases compliance with treatment protocols. By reducing a patient’s arousal, not only will
the patient be satisfied with his or her health care (number 1), but also will be more likely to
comply with the prescribed treatment regimen.
6. Decreases health-care utilization and costs. Compliance is heightened and costs are lowered
by giving patients instructions and treatment protocols when they are more able cognitively
to process them in a baseline emotional state as opposed to a dysregulated state.
There are several steps to managing emotional arousal in suicidal patients (Fruzzetti & Nilsonne,
2004). They include:
1. Identify goals and targets. This requires the provider to stay emotionally regulated him- or
herself and to adopt a nonjudgmental stance toward the patient.
2. Identify targets to validate. These can be the patient’s emotional pain, the patient’s goals, or
problems that are getting in the patient’s way.
3. Redirect the patient to pay attention to some neutral stimulus. If he or she is becoming dysreg-
ulated, direct the patient to the provider’s face (“Look at me.”), an inanimate object in the
room such as a picture, their own breathing, and so forth.
4. Continue to validate as needed. This is to keep the patient feeling understood and focused.
5. When the patient is re-regulated, problem solve. After the patient’s emotional arousal
is down, the original purpose of the visit can be addressed. This may, of course, include
making a referral to specialists, including an appropriate comprehensive mental health
treatment program.
Staff Issues
Many staff issues and reactions can get in the way of effective patient management, especially when
providing care to dysregulated patients who can be hostile and out of control (Fruzzetti &
Nilsonne, 2004). The first are the emotions of the staff member. Staff will no doubt have feelings
of frustration, fear, anger, and sadness, among others when dealing with difficult patients. Staff
can also make negative or critical judgments about the patient’s behavior, or about the staff ’s own
reactions to the patient. It is important to remember that the patient is struggling and is doing
the best he or she can under the circumstances. Also, emotional arousal is typically getting in the
way of the patient behaving effectively and anyone, given the right circumstances (e.g., few personal
resources coupled with extraordinary life stress), could be a difficult patient. It is crucial to focus on
being effective, not belaboring a point so the patient agrees. It is easy to become judgmental about
patients with high emotional arousal and immediately feel frustration when they will not do what
you want them to do. By being effective instead of focusing on being frustrated, you can more easily
and quickly discontinue approaches that do not work and move on to more effective ones.
For the chronically suicidal patient, it is important to assess immediate short-term versus long-term
risk. Linehan (1993) states that active intervention is used to prevent suicide with these types of
patients, but parasuicide per se is not specifically targeted at that moment unless the parasuicidal
act will lead to serious harm. The “life worth living” goal of DBT, pioneered by Linehan, is an
interesting agenda to keep in mind while working with the chronically suicidal patient. A life worth
living generally does not involve continual hospitalization.
Interventive assessment directly dictates the course of treatment. Interventive assessment is
useful because of its targets of re-regulating and reorienting the patient. By reducing emotional
arousal and providing a plan for soothing the patient or solving one or more problems, hospitalization
may not be needed. By staying focused on the aforementioned targets until the present risk is
reduced, the patient can then be referred to appropriate outpatient care. Interventive assessment can
be a vital part of treatment but, of course, hospitalization (or additional intervention) is sometimes
needed as well.
Clinical Examples. The relative utility of interventive assessment and risk assessment is illustrated
in the following alternative ways to handle common presentations in a primary care setting.
Example A: Mary. Mary presented to her PCP for a routine visit. Mary had self-injured (superfi-
cial cutting that did not require medical attention) in the prior 48 hours and reported current
suicidal ideation.
Risk assessment approach. Upon learning of the recent parasuicide, the PCP inquired about
suicidal thoughts (they were present) and did a brief risk assessment that determined that Mary was
at high risk for attempting suicide (i.e., she met criteria for several risk factors including substance
abuse, depression, recent loss, and a history of self-injury). The PCP promptly referred Mary to
inpatient treatment.
Interventive assessment approach. After identifying the parasuicide and current suicidal ideation,
the PCP began to assess for current events in Mary’s life that may have been exacerbating her
suicidality. The PCP learned that she had broken up with her boyfriend, which precipitated her self-
injury. However, her suicidal thoughts were no higher than usual for Mary, and Mary was not
particularly disturbed by them. Moreover, “breaking up” seemed to be a frequent occurrence in
their relationship, followed within days of getting back together. The PCP supported and validated
Mary’s sadness about the loss and fears that they would stay broken up and then quickly began to
problem solve with Mary regarding how to manage either getting back together with her boyfriend
successfully or how to tolerate the loss and seek social support from others in the next 24–48 hours.
Together they made a brief plan for what Mary would do if her suicidality increased. The PCP
referred Mary to appropriate outpatient mental health service personnel, who arranged an appoint-
ment within 72 hours with a local couples therapist to help Mary and her boyfriend with their rela-
tionship, assuming that the current breakup was not, in fact, permanent.
Of course, if the PCP had not been able to develop a collaborative plan that de-escalated the
patient’s immediate risk for suicide fairly quickly (or clearly established that safety could be
achieved in some other way), inpatient treatment could have become an important part of Mary’s
treatment plan.
In this scenario, the chronicity (and predictability) of the patient’s suicidality informed the PCP’s
assessment and intervention strategies. Rather than focusing solely on Mary’s present suicidal
ideation and other relevant risk factors, the PCP was able to reduce the risk to a lower (and more
acceptable) level by focusing on the present emotion and events that were contributing to Mary’s
suicidal thoughts and urges. In addition, the additional assessment made the referrals much more
likely to address and resolve Mary’s pattern of suicidality.
Furthermore, this assessment could have been provided by any number of health-care professionals,
including physicians, nurses, physician’s assistants, onsite therapists, or social workers. In this case
the PCP, on discovering Mary’s recent parasuicide and current suicidal ideation, could have called
in a staff therapist or other mental health practitioner to complete a similar interventive assessment.
Example B: Brian. Brian’s chief complaints were fatigue, sleeplessness, and depressed mood.
The primary care provider, of course, assessed further for depression and Brian disclosed that he
also has been drinking alcohol nightly to intoxication, using methamphetamines several times per
week, and recently was kicked out of his apartment by his girlfriend. He has been staying for the
past several weeks in a room over his brother’s garage. When asked directly about suicidal thoughts
or intentions, Brian was initially evasive, but when pressed he disclosed that he has had thoughts
about shooting himself (his brother keeps several guns in the house).
Risk-assessment approach. The PCP immediately referred Brian for inpatient assessment and
treatment due to the combination of risk status, suicidal thoughts, and access to suicide means.
Interventive assessment approach. The PCP discussed briefly with Brian whether he was willing
and able to stop all substance use and willing to involve his brother in a safety plan. Brian was
ambivalent about his own safety, not willing to commit to getting rid of drugs or alcohol, and did
not want to call his brother. After the PCP spent several minutes trying to understand and validate
Brian’s experiences, Brian continued to seem detached and continued to be unwilling to collaborate
in any kind of safety planning. Consequently, the PCP referred Brian immediately for inpatient
assessment and treatment.
In this example, given the high-risk situation, involvement of substances, access to weapons, and
the unwillingness of the patient to commit strongly to an alternative course all conspired to reduce
effective options. Simply letting the patient go with a referral for outpatient services would not be
advisable in this type of high-risk–low-collaboration situation.
Example C: Christina. This patient presented to her PCP in a mildly agitated state, asking for
medications to help her calm down and sleep. Christina described fits of crying, a lot of fear and
sadness, trouble sleeping, binge eating, and social isolation. A couple of days ago her boyfriend had
left her after finding out that she had been having an affair. Christina reported a lot of shame even
disclosing this to the PCP, and acknowledged that she had not told anyone else about it. When
asked directly about suicidal thoughts she acknowledged having fleeting thoughts about driving off
a bridge or “just dying” when she was feeling overwhelmed, ashamed, and alone, and had cut
herself superficially on the back of her arm twice in the past couple of days (with a history of having
done this several times in the past couple of years).
Risk assessment approach. Based on her risk status, suicidal thoughts, high levels of emotion, and
impulsivity, the PCP referred Christina for inpatient assessment and treatment.
Interventive assessment approach. The PCP validated her feelings, while challenging her suicidality
(e.g., “Of course, when anybody does things that she’s not proud of, and those things mess up our
relationships or hurt others, we feel awful about it. Killing ourselves doesn’t really solve the prob-
lem, however.”). After a few minutes Christina reported feeling a lot better “just having someone
know about her pain.” She did not want to go to a hospital, but was willing to make an appoint-
ment at the local community mental health center having a specialized program for parasuicidal
patients (DBT, see below) for the next day. Because her emotional arousal had abated, Christina was
willing to engage in collaborative problem solving concerning her safety. She agreed, while still with
the PCP, to call her sister, who in turn agreed to have Christina come and spend the night with her
and to go with her to her appointment the next day. The PCP asked Christina and her sister to com-
mit to calling the ER should her suicidal thoughts or urges return before the next day’s appoint-
ment, to which they agreed.
The possible advantages of the interventive approach include (a) patient empowerment
(reinforcing patient collaborative problem solving rather than external control); (b) lower health-
care costs; (c) more immediate involvement of the patient’s social and family network;
(d) integrating the patient’s mental health treatment into the managed care setting, facilitating
coordination, communication, and effective treatment; and (e) likely matching of response to risk.
Of course, risk is not zero, and this approach likely would take 10–15 minutes of a health-care
provider’s time. Thus, it may not always be possible or desirable.
Treating Psychiatric Disorders Associated With Suicidality

As discussed earlier, one of the major factors associated with suicide is a psychiatric condition, in
particular, depression, schizophrenia, substance abuse, or borderline personality disorder. The first
treatment consideration is dealing with these disorders. As soon as the initial crisis has passed,
long-term treatment can begin. Reinecke (2000) quotes Bongar (1991) describing this target of
longer-term care:
If the clinician becomes preoccupied with the issue and threat of a patient’s suicide, it can
divert the clinician from the primary task of attending to more disposition-based treatment-
therapeutics that are solidly grounded in an understanding of the power of a sound therapeutic
alliance and on a well-formulated treatment plan (p. 104).
If depression is the primary disorder, cognitive-behavior therapy could be considered with possible
treatment goals being developing stable and supportive interpersonal relationships and effective
communicating (Reinecke, 2000). Family or marital counseling may also be effective in reducing
depression and resolving interpersonal problems (e.g., Jacobson, Dobson, Fruzzetti, Schmaling,
& Salusky, 1991).
In the case of BPD, dialectical behavior therapy (DBT) has been shown to be effective in reducing
suicidal crises. DBT was first evaluated with a 1-year clinical trial involving 47 chronically parasui-
cidal women meeting criteria for BPD (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991) who
were randomly assigned to either DBT or treatment as usual (TAU). Results indicated that TAU
participants engaged in significantly more parasuicides than did DBT clients during the year of
treatment. Looking at only those participants who were parasuicidal, parasuicides in the TAU
group were of significantly higher medical risk and required significantly more medical treatment
than those participants in the DBT group. Results further indicated that 58% of TAU group partic-
ipants dropped their first therapist in the first year, compared with only 17% of those in the DBT
group. Participants in the DBT group also spent significantly fewer days in psychiatric inpatient
units and incurred substantially fewer costs. Further studies of DBT’s effectiveness in treating
chronically suicidal women and reducing hospitalization and therapist costs can be found in
Koerner and Dimeff (2000) and Fruzzetti (2002).
Of course, many treatments have also proven to be effective in reducing depression and suicidal
ideation. These include cognitive-behavioral therapies and other approaches specific to certain
conditions such as trauma, panic, and posttraumatic stress. Again, depending on the specific disorder,
the treatment should be determined during assessment (see Chambless & Hollon, 1998; Nathan &
Gorman, 1998).
After the short-term crisis has been handled, long-term treatment can consider other factors
besides safety. What are the client’s problem-solving deficits? What is the patient’s psychiatric
disorder? Is the patient receiving good, evidence-based treatment? Are the family and social envi-
ronments stable, or instead reinforcing suicidality or contributing to suicidality? Without attending
to these questions, long-term treatment could quickly turn into long-term crisis management. It is
crucial to treat the thoughts, emotions, behaviors, and life problems leading to suicidality, and
these should be the essence of effective treatment. There are, of course, many empirically supported
psychotherapies and pharmacotherapies to treat depression, schizophrenia, substance abuse,
and other disorders, but appropriate treatment is predicated on thorough assessment, starting
with safety.
Summary
Suicidal crises in a primary care setting are difficult, yet manageable tasks given clear goals and
appropriately trained staff. Two approaches were highlighted: (1) risk assessment, with a focus
on identifying relevant risk factors leading to either hospitalization (higher risk) or outpatient
referral (lower risk), and (2) interventive assessment, with a focus on validation of emotion, problem
solving, and risk reduction, with a target of reducing risk to the point that outpatient treatment or
management is appropriate (lower risk). Also noted was the value of distinguishing between an
acute suicidal crisis that follows a long period of higher functioning without ongoing suicidality,
and an acute exacerbation of suicidality in the context of a long history of chronic suicidality.
The importance of not exacerbating a suicidal crisis or reinforcing a problematic pattern of crisis
behavior in the primary care setting was highlighted. The primary care setting is also an essential
nexus to appropriate referrals, matching referrals to the presenting problems. Consultation among
primary care providers was stressed to alleviate provider burnout, help make balanced decisions in
crises, and limit patient risk and provider liability. Thus, the primary care clinician plays a key role
in the serious clinical presentation of suicidal patients.
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Suggested Reading
Chiles, J. A., & Strosahl, K.D. (1995). The suicidal patient: Principles of assessment, treatment, and case management. Washington,
DC: American Psychiatric Press.
Ellison, J. M. (2001). Treatment of suicidal patients in managed care. Washington, DC: American Psychiatric Press.
Feldman, J., & Finguerra, L. (2001). Managed crisis care for suicidal patients. In Ellison, J. M. (Ed). Treatment of suicidal
patients in managed care. (pp. 15-38). Washington, DC: American Psychiatric Press.
Hilliard, J.R. (1995). Predicting suicide. Psychiatric Services, 46, 223-225.
Kleespies, P.M., & Dettmer, E.L. (2000). An evidence-based approach to evaluating and managing suicidal emergencies.
Journal of Clinical Psychology, 56, 1109-1130.
Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.
Linehan, M.M. (1999). Standard protocol for assessing and treating suicidal behavior for patients in treatment. In
D.G. Jacobs (Ed.). The Harvard Medical School guide to suicide assessment and intervention (pp. 146-187). San
Francisco: Jossey-Bass.
Tanney, B.L. (1992). Mental disorders, psychiatric patients, and suicide. In Maris, R.W., & Berman, A. L. (Eds.). Assessment
and prediction of suicide (pp. 277-320). New York: Guilford.
Chapter 6
Integrating PTSD Services: The Primary
Behavioral Health Care Model
GREGORY A. LESKIN, LESLIE A. MORLAND, AND TERENCE M. KEANE
This chapter provides an overview of current diagnostic strategies and clinical treatment approaches
for primary care patients suffering from the aftermath of emotional trauma. We provide a rationale
to define patients with posttraumatic stress disorder (PTSD) as a clinically special target popula-
tion. By doing so, primary care providers (PCPs) and primary care teams (PCTs) can identify,
provide treatment for, and evaluate outcomes for PTSD patients using both a population-based
approach as well as empirically validated treatments. Further, we provide a theoretical model for
implementing PTSD services within an integrated behavioral health program (as described by
Strosahl, Baker, Braddick, Stuart, & Handley, 1997; Strosahl, 1998) that includes delivery of care
and monitoring of outcomes. In addition, information is presented about educational and skills-
based approaches with an emphasis on coping skills and patient self-management. Finally, we
describe a clinical protocol for treatment of PTSD in a primary care setting, including an analysis of
cost issues for implementing such an integrative approach.
Survivors of trauma often seek care from primary care and emergency room settings for life-
saving and palliative medical attention. However, the traumatic events suffered by these patients
may extend beyond physical injuries and disease states. Many patients seeking treatment in medical
settings also suffer from psychological impairment directly related to the emotional consequences
of a traumatic event. For example, patients injured in vehicular accidents, burned in residential or
industrial fires, shot during crimes, or violated by sexual assault may develop PTSD. PTSD is a psy-
chiatric condition resulting from exposure to these types of highly stressful and life-threatening sit-
uations. In order to qualify for a diagnosis of PTSD, the individual’s emotional response to the
traumatic event must include intense fear, helplessness, or horror. Acute PTSD is diagnosed if the
duration of symptoms has been less then 3 months, whereas a diagnosis of chronic PTSD is made if
symptoms persist longer than 3 months. If the symptoms emerge in the first month following the
event the clinician is urged to consider a diagnosis of acute stress disorder. The onset of PTSD
symptoms can promote a substantial impairment in physical, occupational, or social functioning.
The symptoms of PTSD, as defined in the DSM-IV (American Psychiatric Committee on
Nomenclature and Statistics, 1994), include reexperiencing symptoms such as (a) recurrent and
129
intrusive recollections of the event, (b) recurrent anxious dreams or trauma-related nightmares of
the event, (c) perceptions of the event reoccurring, (d) intense distress or anxiety at exposure to
cues related to the trauma, and (e) physiological reactivity (increased heart rate, sweating) to cues
or reminders of the event. These symptoms are commonly referred to as traumatic memories for
these events (Leskin, Kaloupek, & Keane, 1998).
PTSD is also characterized by continued avoidant behaviors and emotional numbing (Foa,
Riggs, & Gershuny, 1995; King, Leskin, King, & Weathers, 1998). These symptoms include
(a) efforts to avoid thoughts or feelings related to the trauma, (b) efforts to avoid verbalizing details
about the trauma, (c) efforts to avoid people, places, or activities related to the event, (d) loss of
interest in normal, everyday activities, (e) feeling detached or alienated from others, (f) restricted
range of emotions (i.e., feeling numb), and (g) severe limitations to conceptualize a future
that includes positive life experiences. These particular symptoms can adversely affect a patient’s
health care due to his or her inconsistent adherence to medical services or psychotherapy (Shemesh
et al., 2000).
In addition, hallmark symptoms of PTSD include difficulties modulating physiological or
emotional arousal. Arousal symptoms include (a) consistent problems initiating and maintaining
sleep, (b) inappropriate and intense anger at self and others, (c) concentration problems, (d) hyper-
vigilance or scanning for danger cues, and (e) highly responsive startle reactions (i.e., jumping
at loud noises) (Prins, Kaloupek, & Keane, 1995).
The presence of these symptoms after a traumatic event may suggest that the individual contin-
ues to fear the occurrence of additional trauma; that the world feels dangerous, highly unpredictable,
and completely uncontrollable. By addressing these symptoms in the primary care setting, the
patient will be able to increase his or her sense of safety and trust, and, thereby, improve his or her
adherence to medical and mental health treatment. For these reasons, we recommend a more
focused, vertical approach in primary care settings to improve the overall health care of PTSD
patients. Since prior traumatic experience and PTSD may significantly impair the patient’s physical
and mental functioning and adherence to medical care, we recommend PTSD critical pathways be
integrated into primary care settings. According to this model, prior traumatic experiences and
PTSD are routinely screened for and interventions provided in the primary care setting. As we
demonstrate in the following sections, by integrating PTSD critical pathways into primary care
settings, patients with PTSD are provided with psychotherapeutic case management, which
includes psychoeducation about the relationship between trauma and PTSD, coping skills to allevi-
ate associated distress, and brief cognitive-behavioral interventions. We believe such an approach
can improve these patients’ overall mental health status, as well as help to prepare them for
subsequent medical care interventions.
In the sections that follow, we describe the population prevalence rates of PTSD in the community
and with selected at-risk medical populations. Some of these patients will present with undetected
PTSD and overutilize medical services with specific somatic complaints, such as gastrointestinal
upset and pain sensitivity. Further, we suggest that patients with PTSD are frequently diagnosed
with co-morbid and chronic medical disorders, such as arterial, lower gastrointestinal, dermatolog-
ical, and musculoskeletal disorders (Schnurr, Spiro, & Paris, 2000).
Prevalence Rates of Exposure to Trauma and PTSD

Epidemiological studies examining prevalence rates of exposure to extreme trauma have consistently
demonstrated that exposure to a variety of traumatic events is far more common than once
thought. In recent studies examining civilian-related trauma exposure, lifetime exposure to
traumatic events was reported to be as high as 70% in the general adult population (Norris, 1992;
Integrating PTSD Services • 131
Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). Similarly, Kessler, Sonnega, Bromet, Hughes,
and Nelson (1995) describe findings from the National Comorbidity Survey that 60% of men and
51% of women (15–54 years) experienced at least one traumatic event in their lifetime. In the
Detroit HMO study, Breslau, Davis, Andreski, and Peterson (1991) found that 39.1% of a sample of
young adults (aged 21–30) had been exposed to traumatic events during their lifetime.
Two of the most widely studied trauma populations are combat veterans and survivors of sexual
assault. With respect to exposure to combat, Kulka et al. (1990) conducted the National Vietnam
Veterans Readjustment Study (NVVRS), a national epidemiological survey of PTSD among
Vietnam veterans. They found that 64.2% of male veterans who served in Vietnam had been
exposed to one or more traumatic events in their lifetime, compared with 47.8% of men who
served in the military but not in Vietnam and 44.5% of the men who never served in the military.
Estimates of lifetime exposure among women were 70.8% for those who served in Vietnam, 49.5%
for other women veterans, and 37.2% for the nonveteran women.
A national survey of exposure to violence among adult women in the United States (Resnick et
al., 1993) found that 35.6% reported that at some point in their lives they had been the victims of a
crime. Of those exposed to criminal violence, 51.8% of the sample reported they had experienced
more than one type of crime or multiple criminal episodes. With regard to sexual trauma, among
women in the United States, approximately 13% have experienced a completed rape (Kilpatrick,
Edmonds, & Seymour, 1992). Lifetime prevalence rates for sexual assault have ranged from 13–20%
(Koss, 1993).
The prevalence of PTSD is much lower than the prevalence of exposure to potentially traumatic
experiences. That is, a relatively small number of individuals who are survivors of violence, acci-
dents, and disaster actually develop the full set of PTSD diagnostic features. Several well-planned
epidemiological studies have examined the rates of trauma exposure and PTSD in the community
and in primary care settings. In the early 1990s, the National Comorbidity Survey (NCS; Kessler,
1995) conducted face-to-face diagnostic interviews to determine the prevalence of a wide range of
potentially traumatic stressors and mental health disorders in a large nationally representative sam-
ple. The NCS found that 7.8% of respondents were diagnosed with a lifetime history of PTSD. This
prevalence rate is comparable to the PTSD rates of 6% among men and 11% among women found
in the Detroit Health Maintenance survey (Breslau et al., 1991).
Gender Differences
Examination of the rates of trauma exposure across studies does support the presence of significant
gender differences. Much of the research suggests that while males report higher rates of trauma
exposure, females report higher rates of PTSD (Breslau, Chilcoat, Kessler, Peterson, & Lucia, 1999).
One possible reason is that females may be more vulnerable to developing PTSD due to the types of
stressors to which they are differentially exposed. For example, women are exposed more frequently
to sexual assault, which may be more strongly related to the development of PTSD (Boudreaux,
Kilpatrick, Resnick, Best, & Saunders, 1998).
Co-Morbidity of PTSD and Other Psychiatric Disorders

In addition to considering the high rates of PTSD and trauma exposure, patients with PTSD
frequently meet diagnostic criteria for other major psychiatric conditions (Keane & Kaloupek,
1997; Keane & Wolfe, 1990). It is not uncommon for these patients to present with co-morbid
major depression, another anxiety disorder (i.e., panic attacks), and also substance abuse.
The NVVRS found that 50% of veterans with PTSD had a least one other psychiatric disorder.
According to this survey, veterans with PTSD had the following lifetime prevalence rates for
co-morbid psychological conditions: major depression (20%), alcohol abuse (75%), drug abuse
(23%), and personality disorders (20%). According to the NVVRS, males diagnosed with PTSD
were twice as likely to have alcohol-related problems, while women with PTSD were five times more
likely to have alcohol-related problems (Jordan et al., 1991).
Sierles, Chen, Messing, Besyner, and Taylor (1986) at the North Chicago Veterans Affairs (VA)
Medical Center studied co-morbidity in samples of Vietnam veterans with PTSD being treated as
inpatients and outpatients. In both of these groups, more than 80% of the patients were found
to have one or more co-morbid psychiatric disorders. Community studies examining PTSD have
also demonstrated high rates of co-morbid psychiatric disorders. In the NCS, Kessler et al. (1995)
reported 79% of women and 88.3% of the men with PTSD met criteria for another lifetime
psychiatric disorder. The disorders more prevalent for men with PTSD were alcohol abuse or
dependence and history of a major depressive episode.
In sum, PTSD patients frequently present with other psychiatric conditions. These patients may
have had preexisting behavioral disorders prior to their traumatic experiences or developed
other mental disorders (i.e., panic) in reaction to the trauma. Additionally, patients may develop
co-morbid disorders (i.e., substance abuse) as a method to cope or quell the intense emotional
affect related to PTSD.
Traumatic Stress, PTSD, and Physical Health

There is growing acceptance that traumatic exposure and PTSD are linked to poor physical health,
greater utilization of medical care, and higher overall morbidity (Rosenberg et al., 2000; Taft, Stern,
King, & King, 1999). For example, a recent meta-analysis compared the results of seven studies
examining sexual assault history and health perceptions (Golding, Cooper, & George, 1997). A his-
tory of sexual assault was associated with a 46% increased likelihood of poor subjective health, even
after controlling for the effects of major depression. Friedman and Schnurr (1995) investigated
health functioning in combat veterans, sexual assault victims, and disaster survivors. Traumatic
exposure was related to poor outcomes in four categories: self-reported physical health and symp-
toms, utilization, morbidity as indicated by physician diagnosis, and mortality. Accordingly, PTSD
was proposed as a primary mediator between traumatic life experiences and these poor physical
health outcomes.
Several investigations have demonstrated relationships between lifetime trauma histories and
specific medical diagnoses, even years after the trauma occurred. Some examples include cardiovas-
cular disease (Falger et al., 1992), gastrointestinal disorders such as irritable bowel syndrome
(Drossman, Li, Leserman, Toomey, & Hu, 1996; Leserman et al., 1996), chronic pelvic pain (Reiter,
Shakerin, Gambone, & Melburn, 1991), and fibromyalgia (Lutgendorf et al., 1995). In addition,
recent research indicates that male Vietnam veterans with PTSD were at higher risk for atrioven-
tricular conduction defects and infarctions (Boscarino & Chang, 1999).
A possible explanation for these reductions in physical health status in PTSD patients is that hor-
mones released in the brain (e.g., glucocorticoids, catecholamines) during stressful events can damage
bodily systems (Sapolsky, 1996). During stress, these hormones mediate the activation and regulation
of central and peripheral nervous system processes in order to respond to environmental demands.
According to the theory of allostatic load (McEwen, 2000), continued activation of these brain pro-
cesses, such as in PTSD, may result in atrophy of biological systems, leading to disease states.
Life-threatening medical conditions, including heart attack, cancer, and asthma, may also
contribute to the causation or worsening of PTSD. For example, research now exists suggesting that
invasive types of medical procedures, such as bone marrow and liver transplantation (Walker et al.,
1999) and breast cancer (Mundy et al., 2000), can meet criteria as traumatic stressors. Jacobsen
and colleagues (1998) found that about 15% of females undergoing autologous bone marrow
transplantation (ABMT) for breast cancer met criteria for a current diagnosis of PTSD. Follow-up
studies suggest that these women continued to suffer from PTSD 12 months after their surgeries
(Andrykowski, Cordova, McGrath, Sloan, & Kenady, 2000).
Population-Based Care for PTSD

A population-based management approach starts with a basic understanding of the prevalence
rates of trauma and PTSD in primary care settings. Recent epidemiological studies of PTSD in
outpatient medical settings have found high rates in both general community settings, as well as
with patients known to be at risk due to prior trauma exposure. Samson, Bensen, Beck, Price, and
Nimmer (1999) examined the prevalence of PTSD in patients at Kaiser Permanente in Denver, CO,
with histories of anxiety or depression. Among those patients, 38% were diagnosed with PTSD.
Stein, McQuaid, Pedrelli, Lenox, and McCahill (2000) examined 1-month rates of PTSD in a com-
munity primary care clinic. About 12% of primary care enrollees were diagnosed with PTSD. This
study also determined that over 60% of patients who complained of depression, also met criteria
for PTSD.
In another recent study conducted in Israel, Taubman-Ben-Ari, Rabinowitz, Feldman, and
Vaturi (2001) screened for PTSD in a representative sample of patients from 26 Israeli primary care
clinics. Of 2,975 patients, 37% of males and 40% of females met criteria for current PTSD diagnosis.
In the Veterans Health Study, Hankin, Spiro, Miller, and Kazis (1999) screened for PTSD in a large
random sample of males seeking care from a VA ambulatory care clinic in the northeastern United
States. Twenty percent of the sample met diagnostic criteria for lifetime PTSD. Further, 82% of
those patients with PTSD also met criteria for a depressive disorder. These two groups may repre-
sent at-risk groups for PTSD because of the patient’s higher potential for exposure to combat or
wartime violence.
Assessment
Compelling evidence suggests that PTSD is one of the most common anxiety disorders in primary
care (Fifer et al., 1994; Sampson et al., 1999). It also appears that patients with a history of trauma
and PTSD have a greater preference to seek help from a primary care practitioner rather than a
mental health provider (Druss & Rosenheck, 1997; Murdoch & Nichol, 1995). Further, there are
multiple studies indicating that individuals exposed to trauma have an increased likelihood of poor
self-reported health possibly leading to increased utilization of medical services (Rosenberg et al.,
2000). In a recent set of analyses, Deykin et al. (2001) found that high users of VA medical services
are almost twice as likely to have a diagnosis of PTSD than those who use primary health-care
services less frequently. Further, the veterans with the most severe PTSD tended to have the highest
mean number of physician-diagnosed medical conditions. Despite these findings, most medical
and community mental health settings do not routinely screen for trauma exposure or PTSD
(Leskin, Ruzek, Friedman, & Gusman, 1999).
Several barriers may account for the lack of attention paid to the assessment of trauma exposure
and PTSD in primary care. Many clinicians are not trained to ask about recent or lifetime trauma
exposure or specifically about PTSD. Some clinicians assume patients will readily disclose
trauma exposure or symptoms of PTSD. However, PTSD patients may be waiting to be asked about
these experiences or they are socialized to focus on medical symptoms during a physician examina-
tion. Clinicians may feel uncomfortable, embarrassed, or intrusive asking patients about the
patient’s trauma exposure or PTSD symptoms. However, a majority of primary and specialty care
patients indicate that they would like to be asked about their traumatic events more directly
(Friedman, Samet, Roberts, Hudlin, & Hans, 1992; Robohm & Buttenheim, 1996).
Providers may think that asking about previous trauma will cause the patient to become unnec-
essarily distressed or agitated. Also, primary care providers may decide that encouraging disclosure
about traumatic experiences will lead to additional staff resources and work to assist the patients
with their life circumstances. All these potential barriers may certainly play a role in the decision
about whether or not to routinely screen for trauma and PTSD in primary care settings. However,
actively screening for trauma, PTSD symptomatology, and associated risk factors can aid in
implementing both primary and secondary prevention within an integrated health-care service
delivery model.
Brief Measures
One approach to screening PTSD in the primary care setting is to embed a brief trauma exposure
measure and PTSD symptom screen into a primary care self-report evaluation. These measures can
be used to quickly identify PTSD symptoms as well as unhealthy or risky behaviors. This approach
may be appealing because of the previously discussed relationship between PTSD and health risks.
The Education Division of the National Center for PTSD has developed a PTSD screen, the
Primary Care PTSD (PC-PTSD) screen (see Table 6.1), which can be embedded within the original
PRIME-MD patient problem questionnaire (Prins, 2004) or other patient health questionnaires.
This 4-item screen assesses for current PTSD without a specific trauma probe question. Using a
sample of mostly female VA patients (N = 70) and the Clinician Administered PTSD Scale (CAPS)
as a diagnostic “gold standard,” endorsement of any two items resulted in adequate sensitivity and
positive predictive power (.68 and .60, respectively) and excellent specificity and negative predictive
power (.91 and .93, respectively). The overall efficiency of this screen was very good (.88). Based on
these findings, it is recommended that when administering the PC-PTSD the results of the screen
should be considered “POSITIVE” if a patient responds “YES” to two or more of the screening
items. A positive response to the screen does not necessarily indicate that the patient has PTSD, but
rather it indicates that a patient may have PTSD and that further investigation is warranted.
The Pacific Island Division of the National Center has investigated the use of a trauma
measure—Traumatic Life Events Questionnaire (TLEQ)—and a PTSD measure—Distressing Event
Questionnaire (DEQ)—in various settings, including family practice, outpatient psychiatry, and a
substance abuse program. Both measures have demonstrated good validity and reliability across
trauma populations (Kubany, Haynes et al., 2000; Kubany, Leisen, Kaplan, & Kelly, 2000). Using a
sample of male veterans (N = 120) and the CAPS as a diagnostic gold standard and employing a
cutoff score of 26, the DEQ demonstrated adequate sensitivity and positive predictive power
(.87 and .78, respectively) and excellent specificity and negative predictive power (.85 and .91,
receptively). The overall efficiency of the screen was again very good (.86). Using female trauma
survivors (N = 255) and the CAPS as a diagnostic gold standard (a cutoff score of 26), the DEQ
TABLE 6.1 PTSD Primary Care Screen

Have you ever had an experience that was so frightening, horrible, or upsetting that, in the past month, you …
a. Have had nightmares about it or thought about it when you did not want to? YES NO
b. Tried hard not to think about it or went out of your way to avoid situations YES NO
that reminded you of it?
c. Were constantly on guard, watchful, or easily startled? YES NO
d. Felt numb or detached from others, activities, or your surroundings? YES NO
demonstrated adequate sensitivity and positive predictive power (.90 and .88, respectively) and
adequate specificity and negative predictive power (.58 and .88, respectively). The overall efficiency
of the screen was good (.90). Although these measures cannot be considered screens because of
their length, they do offer a comprehensive, self-reporting assessment of various events and PTSD
symptomotology.
The TLEQ should be used in combination with the DEQ. When used together, the question-
naires constitute a trauma history and PTSD screening protocol. Both measures are purposefully
brief to be used in both mental health and medical settings. In addition, the utility of abbreviated
versions of these measures is currently being investigated.
The most widely used measure of PTSD is the CAPS (Blake et al. 1995; Weathers, Keane, &
Davidson, 2001). The CAPS uses a structured interview process to assess the frequency and
intensity of the 17 DSM-IV core symptoms of PTSD and associated symptoms. Through repeated
psychometric studies, the CAPS has demonstrated sound reliability and validity, and it provides a
highly accurate diagnosis of PTSD. Although clearly more time intensive than the TLEQ and DEQ,
the CAPS does provide the clinician with more clinically rich data about the specific symptoms and
their course over time.
Although a complete overview of PTSD diagnostic assessment is not possible here, several excel-
lent texts are available that detail these issues (for reviews see Blanchard & Hickling, 1997; Briere,
1997; Wilson & Keane, 1997). It is recommended that a brief screen for PTSD, such as the four-item
Primary Care PTSD Screen, be integrated into an initial patient assessment packet in order to
routinely assess for the presence of PTSD symptoms. If necessary, a complete psychological assess-
ment would reduce false positives from the screening procedure so that psychological interventions
can proceed with patients who have subthreshold or acute PTSD. This psychological assessment
should incorporate an assessment of traumatic exposure (e.g., TLEQ) and a structured interview
for PTSD (e.g., CAPS).
Acute Stress Disorder

Once trauma and PTSD have been screened, several options exist for clinicians within the primary
care setting to use psychotherapeutic methods to minimize trauma-related distress. Immediately
following trauma, critical incident stress debriefing (CISD) may be a viable treatment to reduce the
likelihood of developing PTSD among certain patients. CISD consists of a single retelling of facts
(usually within a group format) related to the traumatic incident soon after the individual is within
a safe and comforting environment to discuss these details. This approach has been widely used
following natural and technological disasters, airplane and automobile accidents, and mass shoot-
ings (Everly, Flannery, & Mitchell, 2000). Although there is a lack of controlled, randomized trials
of CISD, the research suggests that CISD may be most effective for those with less direct exposure
to the trauma, for example, emergency care personnel exposed to the death of others (Bisson,
McFarlane, & Rose, 2000). One potential use of the CISD approach is to identify those individuals
at most risk for developing PTSD who require more intensive and direct intervention. Others have
recommended that psychological debriefing be integrated within a comprehensive traumatic stress
management program (Dyregrov, 1997).
There is evidence that more intensive treatment may be necessary for victims of severe and direct
trauma. Foa, Rothbaum, Riggs, and Murdock (1991) provided four sessions of psychotherapy to
female rape victims and nonsexual assault victims about 3 weeks following their assault. This inter-
vention included education about the connection between trauma and PTSD, relaxation exercises,
imaginal and in vivo exposure, and cognitive restructuring. When compared with the matched
controls, individuals receiving this preventative care had fewer complaints about traumatic memo-
ries and were significantly less depressed 5 months postassault. Similarly, Bryant, Moulds, and
Guthrie (2001) used cognitive behavioral therapy immediately following moving vehicle accidents.
There were fewer cases of PTSD among patients who received a five-session package consisting of
prolonged exposure therapy, anxiety management, and cognitive restructuring exercises. In the
sections below, we describe some of these treatment techniques in greater detail for use in primary
care management of traumatized patients.
Primary care providers in traditional medical settings can conduct debriefings or acute interven-
tions following acute traumatization. The physician or mental health provider can incorporate
brief, one-session individual, family, or group debriefings into a medical examination. The focus of
these sessions should be on assessment for continued treatment, providing psychological first
aid(e.g., ensuring the patient’s safety), psychoeducation about trauma, and information about
treatment options (Litz, Gray, Bryant, & Adler, 2002).
Treatment Options for PTSD

A number of different psychological and pharmacological treatments have been recommended for
PTSD (see reviews by Foa, Keane, & Friedman, 2000; Friedman, 2000; Leskin et al., 1998). Some
patients with more disabling forms of PTSD will require a more intensive treatment approach that
includes both types of interventions. Cognitive-behavioral treatment interventions have received
the most empirical study and include methods such as exposure therapy, cognitive therapy, anxiety
management training (e.g., breathing exercises), and social skills training.
Here, we provide an overview of those elements of CBT and psychosocial interventions that may
be useful in a brief treatment model for patients seen in primary care settings. Some PTSD patients
require a referral for more intensive treatment in a specialized mental health setting for reduction
of their PTSD; for these individuals a lengthier course of treatment may be required. For example,
patients with chronic forms of PTSD, multiple lifetime traumatic events, or poor adherence to
treatment plans may require more intensive, specialized PTSD treatment.
Cognitive-Behavioral Treatment for PTSD

The current treatment of choice for chronic and severe cases of PTSD is behavioral and cognitive-
behavioral methods, including exposure-based approaches (Solomon, Gerrity, & Muff, 1992;
Keane, 1998; Tarrier et al., 1999). During an imaginal exposure therapy session, the patient recalls
their traumatic experience in detail while also processing their emotional reactions during the event
(for a detailed explanation of this therapeutic intervention, see Keane, 1998, and Foa & Rothbaum,
1997). Through repeated therapy sessions, exposure therapy provides a structured approach to
directly reduce the distress related to the reprocessing of traumatic memories. Several recent studies
have found that exposure-based therapy is a safe and effective therapy for treating the chronic
forms of PTSD (Tarrier et al., 1999; Tarrier & Humphreys, 2000). Tarrier et al. (1999) have demon-
strated that PTSD patients improved from exposure therapy on multiple outcome measures even
after a 12-month follow-up assessment.
In addition, cognitive therapy can assist patients in reinterpreting the meaning of the traumatic
events, in order to assist the patient to reestablish a sense of safety and control in his or her life and
reduce guilt or shame related to the trauma (see Ehlers & Clark, 2000; Kubany, 1998 for descriptions
of cognitive therapy for PTSD). Strategically, the main purposes of the cognitive interventions are
to reappraise the traumatic event in terms of personal responsibility and develop adaptive self-talk
to regain a sense of calm and safety. In addition, cognitive therapy can be helpful to reduce
distorted or unhealthy cognitive coping strategies, such as harsh self-punishment or thinking of
oneself as undesirable or defenseless (Resick & Schnicke, 1992).
Psychosocial Intervention
Psychosocial interventions are techniques focused on improving daily living skills and interpersonal
interaction. Psychosocial rehabilitation is often appropriate for individuals with disorders that
impact daily living and who demonstrate needs in social functioning related to day-to-day living.
Most psychosocial interventions are general in nature and not specific to symptoms of a disorder
but rather target the by-products of the disorder. Owing to the impact PTSD can have on daily
living, such as health, social, and occupational functioning, psychosocial techniques are recom-
mended as an adjunct to accompany the cognitive and behavioral treatments for PTSD.
The approach taken with psychosocial intervention is often problem-focused, when an individ-
ual identifies a problem associated with the PTSD, then together the individual and the clinician
can generate behavioral strategies to resolve the problem. Techniques typically include (a) health
education and psychoeducation, (b) self-care and independent-living skills training, (c) supportive
housing, (d) family skills training, (e) social skills training, (f) vocational rehabilitation, and (g) case
management (Penk & Flannery, 2000).
Psychosocial interventions may be most appropriate in the cases of chronic PTSD where the
symptoms over time have created difficulty in day-to-day living. Psychosocial interventions are also
appropriate in the later stages of PTSD treatment in which the individual is prepared to reestablish
social interactions and positive emotional experiences that have been adversely affected by the trau-
matic event.
Integrated PTSD Services Into Primary Care Settings

According to the Primary Behavioral Health Care Model (Robinson, Wischman, & Del Vento, 1996;
Strosahl, 1998) defined target populations with specific mental health disorders are screened and
treated by the primary care team within the primary care clinic. Behavioral health-care specialists
work together with the medical staff to develop critical pathways for routine screening, collabora-
tive case management, treatment, and follow-up of those screened positive for disorders requiring
selective staff attention. In addition, this integrated model requires rapid turnover of cases using
brief interventions. Those cases that require more intensive secondary treatment are referred to
specialized behavioral health-care treatment specialists. Table 6.2 demonstrates a PTSD model inte-
grated into primary care settings based on the Primary Behavioral Health Care Model.
Because PTSD is a relatively new clinical diagnosis, less empirical research is available to evaluate
the effectiveness of treating PTSD within the Primary Behavioral Health Care Model. In fact, the
majority of PTSD treatment services to date have been in traditional outpatient and inpatient
mental health settings, such as those at the Department of Veterans Affairs (Fontana & Rosenheck,
1997). However, several brief treatment strategies for PTSD may be incorporated using the
approach proposed herein. For example, it seems plausible that patients screened positive for PTSD
can receive educational materials, self-management exercises, and even instructions to write out the
details of the trauma at home as an exposure-type treatment.
Costs and Value

There is increasing evidence that PTSD is associated with the highest rate of mental health service
use and has one of the highest per capita costs of any mental health disorder (Kessler, 2000) In addi-
tion, Walker, Harris, Baker, Kelly, and Houghton (1999) found substantially increased overall
health-care costs associated with female patients who reported histories of childhood abuse and
neglect. In their study of 1,225 randomly selected women from an HMO, those women who
reported prior trauma histories had median annual health-care costs that were $97 more than
TABLE 6.2 A Framework for Integrated Primary Care Behavioral Health: PTSD Critical Pathways
Approach General Goals Specific PTSD Goals
1. Program planning Population-based care planning Trauma, PTSD, and co-morbid
approach framework based in epidemiological diagnosis routinely screened for and
assessments; priority behavioral health treated in primary care settings
needs addressed in resource allocations
2. Integration models System employs at least one critical PTSD assigned “critical pathway status”
employed pathway (vertical) and general behavioral
health services (horizontal)
3. Predicted High population impact; services target High impact on traumatized
population impact high areas of behavioral health needed; populations (i.e., veterans, domestic
service density great enough to service a violence, sexual abuse); increase in
variety of behavioral health needs; large number of patients identified with
cost returns possible because of multiple PTSD; potential for cost returns
population targets because of high utilization of this
patient population
4. Service locations Onsite services delivered within medical Use of both primary care and specialty
practice area as part of general PTSD treatment settings
health-care processes
5. Service philosophy Behavioral health-care integrated into Patients provided with treatment in
primary medical practice; both services primary care (psychoeducation,
integrated in primary care team; goals coping skills, psychopharmacology);
consistent with primary mental chronic, complex, and difficult cases
health-care model referred to specialty care settings
6. Service Behavioral health delivered in Practice guidelines for PTSD screening,
characteristics consultation model; physician remains in diagnosis, referral, and education in
charge; visit pattern designed to integrate primary care settings; brief
activities of both providers seen by interventions employed
patient as adjunct to primary care teams;
service length is short by program design;
primary care access standard used
7. Service penetration 20% or more; program capacity great due Same as general goals
to consultative services and multiple
critical pathways
8. Referral and case Program reduces physician referrals for Same as general goals
finding impacts specialty mental health by at least 50%;
20% or fewer patients enrolled in
program referred on to specialty care
9. Ongoing evaluation Physicians, mental health providers, and Continued evaluation of services and
and training staff continue ongoing evaluations and population impact (i.e., costs, service
training for integration practices; utilization, clinical outcomes); patient/
patients and other consumers provided staff satisfaction determined
with education about system changes
Note. Adapted from Strosahl, 1998 and Strosahl et al., 1997.
women without childhood abuse and neglect. For those women with histories of prior sexual
victimization, the median annual health-care costs were as much as $245 greater even after controlling
for the effect of chronic disease burden. Although the goal of any health-care organization should
be on quality of care rather than costs, these figures do illustrate the direct financial burden that
trauma histories play on the provider and, more broadly, on health-care systems. The empirical
literature has, to date, not considered whether brief interventions in the primary care setting would
actually reduce the overall health-care costs of these patients. However, the available research does
suggest that psychotherapeutic interventions can reduce the pain and distress associated with PTSD
(Foa et al., 2000).
Summary
In this chapter we have demonstrated a rationale for the development and implementation of PTSD
services integrated into primary care settings. PTSD is a debilitating emotional disorder that results
from exposure to traumatic experiences. In its more chronic forms, PTSD can adversely impact an
individual’s physical and mental functioning. Effective psychotherapeutic treatments are available
to reduce the patient’s suffering and improve adherence to medical care. More empirical research is
necessary, however, to determine the effectiveness on long-term clinical outcomes by using such an
integrated behavioral health-care model.
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Chapter 7
Identification and Treatment of Substance
Abuse in Primary Care Settings
JANET L. CUMMINGS
The Impact of Substance Abuse on Medical Treatment

In the late 1970s, a 45-year-old longshoreman underwent simple surgery in a California Kaiser
Permanente hospital. What should have been a 3-day hospital stay instead lasted over 3 weeks.
Shortly after the surgery, the patient began hallucinating and, as a result, tried to jump out the
window. He ripped open his incisions several times, tearing himself out of restraints each time.
Severe infection resulted, which required intravenous antibiotics and constant monitoring by
nursing staff. A treatment team consisting of physicians, nurses, and mental health professionals
determined that the patient was an alcoholic, and that anesthesia medications in combination with
alcohol withdrawal had precipitated the hallucinations. The hallucinations, in turn, prompted the
patient’s self-destructive behavior, which jeopardized his healing and caused his hospital stay to
become so protracted.
This case prompted an in-house research project to assess the effects of substance abuse on
medical conditions, surgery outcomes, and hospitalizations for medical problems (Kaiser
Permanente Health Plan, 1981). The study found that substance abuse significantly affected all
these medical arenas.
For example, the study looked at patients hospitalized for medical conditions and found that the
hospital costs for substance abusers were 2 ½ times the hospital costs for nonsubstance abusers hos-
pitalized for the same condition. Two factors accounted for the increased costs: (1) the substance-
abusing patients stayed in the hospital significantly longer than the nonsubstance-abusing patients
hospitalized with the same condition; (2) the substance-abusing patients required more medical
interventions during their stays owing to significantly increased rates of both medical complica-
tions and healing time. Following the hospital stays, substance-abusing patients continued to utilize
more medical services than nonsubstance-abusing patients with the same condition. Two factors
accounted for these increased posthospitalization costs: (1) the substance abusers were notoriously
noncompliant with medical treatment, often ignoring the directions of their physicians and failing
to keep follow-up appointments until problems became severe enough to require much more costly
143
interventions; (2) substance abuse greatly retarded the healing process, often creating additional
medical problems to compound the original problems.
The Kaiser Permanente study also determined that alcoholism was the most costly complication
of diabetes in the population studied. Alcoholic diabetics had far more complications than nonsub-
stance-abusing diabetics, because of both the direct effects of the alcohol on blood sugar levels and
the patients’ noncompliance with their physicians’ directives.
The study also found that 6% of the patient population accounted for 73% of physician visits for
nasopharyngitis. These 6% were cocaine abusers experiencing irritation and inflammation of the
nasal passages and pharynx from their “snorting.”
Heroin addicts who underwent surgery, even simple surgery, were even more costly to manage
during the recovery period than were the alcoholics who had surgery. These individuals had
developed a high tolerance to the most potent analgesic known (heroin), so the Demerol or even
morphine administered at proper dosages had little or no effect on these patients’ pain. They were
very demanding patients, requiring excessive time from physicians and especially nurses. Many
threatened physical violence or litigation, blaming the medical staff for their inability to alleviate
the postsurgical pain.
The 7-year study known as the Hawaii Project also looked at the added costs of treating substance
abusers for medical conditions using a 36,000 Medicaid population and 90,000 population of federal
employees (Cummings, Dorken, Pallak, & Henke, 1991, 1993). The prospective, randomized study
looked at three groups of subjects: (1) patients receiving no treatment, (2) patients receiving targeted
and focused psychotherapy, and (3) patients receiving other mental health treatment. The greatest
cost savings found in the project were among substance abusers who received appropriate substance-
abuse treatment. The medical savings here was significantly greater than for the chronically medi-
cally ill, phobics, somatizers, or any other group studied.
Appropriate treatment for substance abusers resulted in a savings of $700 per patient per year.
However, inappropriate treatment for substance abusers actually increased medical costs by close to
$1,000 per patient per year. The cost of medical treatment for no treatment controls increased only
slightly. The cost savings for the chronically medically ill subjects receiving focused and targeted
psychotherapy was quite impressive, but less than for the substance-abusing subjects. For the
chronically medically ill, targeted and focused psychotherapy resulted in a savings of about $500
per patient per year, with other (inappropriate) mental health treatment increasing medical costs by
about $800 per patient per year and no treatment, resulting in a very slight increase in costs.
As these and other studies demonstrate, the potential savings in health-care dollars by the appro-
priate assessment and treatment of substance-abusing patients is enormous. Add to this the savings
that could result from decreasing injuries and deaths from auto and industrial accidents, decreasing
lost workdays, and increasing productivity. The amount of money potentially saved by appropri-
ately assessing and treating substance abuse becomes incalculable.
Prevalence Rates: Who Is the Substance Abuser?

Hard-core addicts are generally easy to spot. Most health-care providers are trained to recognize the
bulbous nose and pasty skin characteristic of hard-core alcoholics and the track marks characteristic
of longtime intravenous drug abusers. However, most addicts are not this easy to recognize,
especially when the addict is a neighbor, a coworker, or a colleague.
According to the National Institute on Drug Abuse (NIDA) and the National Institute on
Alcoholism and Alcohol Abuse (NIAA), about 35 million Americans abuse alcohol. About half that
number (or 17 million) abuse marijuana. A startling 40 million abuse legal drugs (both prescrip-
tion and over-the-counter varieties). Following a period of decline, heroin abuse is on the rise,
Identification and Treatment of Substance Abuse • 145
with about 3 million heroin addicts in the United States at this time. About 4 million Americans
regularly abuse cocaine (including crack cocaine) and about 5 million regularly abuse amphetamines
(including methamphetamines). About 11 million regularly abuse barbiturates (Cummings &
Cummings, 2000; NIDA & NIAA, 1999).
Attempting to add these numbers would lead to an overestimation of the number of substance
abusers. There is considerable overlap, as most substance abusers these days engage in polysub-
stance abuse (NIDA & NIAA, 1999). In fact, pure alcoholics (those who only abuse alcohol) are
seen less and less frequently and are 45 and older. Although exact numbers are difficult to obtain,
estimates place chemical abuse and chemical dependency in America at a low figure of 15% and
a high figure of 20% of the total population. In other words, one in six or one in five Americans is a
substance abuser (Cummings & Cummings, 2000; Falco, 1992; NIDA & NIAA, 1999).
Surprisingly, NIDA and NIAA report that 71% of substance abusers are employed (NIDA &
NIAA, 1999). Most of these have health insurance and are therefore potential patients in both
behavioral health and primary care settings. Only about 21% of substance abusers are unemployed,
marginally employed, homeless, or in prison (U.S. Department of Labor, 1998).
The implications of these figures for primary care practice are astounding. In settings where only
patients with employer health insurance are seen, probably as many as one in five or one in six are
substance abusers. In settings that serve persons covered by Medicaid, Social Security Disability,
and Medicare, the figure will be even higher, with as many as one in two or one in three patients
being substance abusers (Cummings & Cummings, 2000; NIDA & NIAA, 1999).
In this chapter the terms “abuse,” “addiction,” and “dependency,” as well as the terms “addict”
and “substance abuser,” are used interchangeably. Physical craving for the substance upon
withdrawal is not the defining characteristic of addiction, as many believe, since not all abused
substances produce such physical cravings. The unfortunate consequence of the erroneous belief
that addiction is defined by physical cravings is that it has led much of the medical profession and
public to believe that any substance yet to be declared medically addictive carries no potential for
addiction. Nor is heavy use over long periods of time the defining characteristic of addiction,
as some nonaddicts can engage in heavy use over a period of time. (For example, the amount of
alcohol consumed at some college parties can be alarming enough to look like incipient alcoholism
in many of the participants, although many who engage in such behavior in college do not go on to
become alcoholics.) (Cummings & Cummings, 2000).
Rather, the “addict” or “substance abuser” is someone who continues to imbibe after a series of
consequences, any one of which would lead the nonaddict to decide that the chemical simply is not
worth it. In other words, the defining characteristic of substance abuse or addiction is trouble—the
kind of trouble that would not occur without the substance abuse. If a person continues to use a
substance despite recurring trouble (legal, marital, occupational, health-related, etc.), it is an indi-
cation that he or she is addicted. Characteristically, the addict is the last to realize that the trouble is
the result of the substance abuse. Since continued frequent intoxication will inevitably result in
trouble sooner or later, the terms “addiction,” “substance abuse,” and “chemical dependency”
become interchangeable rather than somehow defining the degree of abuse. Again, it is the trouble
that defines the abuse (Cummings & Cummings, 2000).
Who Is Supplying Substances to Addicts?

The term “pusher” conjures up stereotypic images of shady characters lurking just outside fenced
schoolyards or of thugs waiting in secret inner-city meeting places (such as crack houses) to sell
their wares. These are not the most common pushers in the United States today, nor the most
worrisome. The real pushers, the ones who should cause the most concern, look like our neighbors,
coworkers, classmates, friends, and colleagues. The drug lord or mafioso is many steps removed, so
that in many cases the addict is also the pusher. Addicts often become pushers or dealers of street
drugs in order to supply their own habits. Each obtains a supply, removes what he or she needs for
personal use, then dilutes the remainder to sell in order to have money to purchase the next supply.
(Thus, the purity and potency of street drugs depends on how many times they have been diluted.)
The number of prescription drugs being resold is alarming. Nearly one third of Ritalin pre-
scribed to school children is being resold by these same children, who often use the money to
purchase amphetamines or crack cocaine for themselves. Pain patients who have “graduated” from
prescription codeine to more highly refined street opiates often sell their prescription medications
on the streets (at inflated prices) in order to pay for their more potent narcotics (Cummings &
Cummings, 2000; Moore, 1998).
With all due respect to the medical profession, the pusher is often a physician. Although physi-
cians are generally well meaning, a small minority of unscrupulous physicians are knowingly
dealing drugs. Because such a physician issues an enormous number of prescriptions for a certain
type of drug, he or she needs to present the appearance that these prescriptions are legitimate. For
example, he or she may claim to specialize in weight reduction so as to explain the large number of
prescriptions for amphetamines being issued. Some physicians are so unscrupulous that they
knowingly addict their patients to drugs in order to have them provide a steady income stream
(Cummings & Cummings, 2000).
More commonly, the physician pusher is kindly and well meaning. He or she wants to alleviate
all pain and discomfort. This physician overly prescribes narcotic pain killers, sleeping pills, and
other mind-altering drugs. He or she is too naive to recognize the addicted patient, who always
comes in requesting a specific drug and yet obtaining the same drug from a number of other physi-
cians so that no one physician is aware of the full extent of the patient’s drug use. The pusher may
also be an “impaired” (addicted) physician who, because of his or her own chemical dependency,
cannot stand to see a patient in withdrawal. Such physicians fail to recognize that their addicted
patients typically present themselves as suffering far more than they actually are (Dejong & Doot,
1999; Earl, 1988; Green, Carroll, & Buxton, 1978). Thus, they are quick to provide a prescription to
carry the patient until he or she can obtain the illegal drug of choice or to continue issuing
prescriptions for drugs that no longer have a legitimate medical use rather than see these patients
suffer the discomfort of withdrawal (Earl, 1988; Moore, 1998).
One factor that contributes to some well-meaning physicians’ drug pushing is the fact that an
addict is addicted to an entire class of drugs rather than to a single drug within that class. The
addiction is perpetuated rather than alleviated when other drugs belonging to the same class are
administered in an attempt to treat the addiction. For example, abuse of alcohol (a central nervous
system depressant) has traditionally been treated using other types of central nervous system (CNS)
depressants, particularly the benzodiazepines (such as Valium, Xanax, and Librium). With such
treatment, the patient does not learn to live without alcohol, but simply learns to accept an “alcohol
equivalent” instead. In many cases, the alcoholic uses his or her prescription medication in addition
to alcohol rather than instead of it, which is a potentially lethal combination. Many patients who
were addicted to older barbiturate medications have been switched to newer benzodiazepines, but
these serve only to perpetuate the addiction to CNS depressants. Methadone clinics attempt to treat
heroin addiction by substituting methadone for heroin, even though methadone withdrawal is
more difficult than heroin withdrawal and recovery from methadone addiction is more difficult
than recovery from heroin addiction (Cummings & Cummings, 2000).
Another factor that contributes to prescription drug-pushing by well-meaning physicians is that
addicts present as anything but addicts, both in mental health settings and in primary care. In
mental health settings, the addict who has been sent to treatment by a spouse, employer, or judge
may mention the substance abuse but deny that it really exists. Those who self-refer for mental
health services present with everything except substance abuse, generally reporting the conse-
quences of the abuse (marital problems, occupational problems, legal problems, etc.) but never
mentioning the abuse itself. In primary care settings, some substance-abusing patients mention
these same consequences to their physicians, who quickly change the subject to a discussion
of physical symptoms.
Other substance-abusing patients fail to mention such consequences to their physicians. Rather,
they present with purely physical symptoms. These symptoms, on the surface, often seem like just
that—symptoms of some physical illness. However, they are ploys used by addicted patients to
obtain the drugs they want. For example, a patient may complain of anxiety or insomnia in order
to obtain a prescription for benzodiazepines. The reported symptoms may be contrived or due to a
rebound effect from using the very drug desired. A patient may complain of chronic, debilitating
pain in order to secure a prescription for narcotics. Again, the reported symptoms may be contrived
or due to pain that began as a physical problem but is being perpetuated by the addiction and
psychological factors.
The elderly are most vulnerable to becoming addicted to prescription medications, and most
chemical dependency among the elderly is iatrogenic (Hartman-Stein, 1998; Kaplan & Sadock,
1993). Physicians do not consistently warn patients not to use alcohol in combination with
prescription medications where alcohol use would be contraindicated (Hartman-Stein, 1998;
Joseph, 1997). Older adults have less tolerance for alcohol than younger adults, and may need less
prescription medication (often less than what would be indicated by standard dosage ranges) to be
effective. Physiological differences in the elderly (including slowed absorption rates, decreased
availability of plasma proteins, declining liver functioning, and decreased kidney function) can cause
them to react differently than do younger people to certain medications (Gitlin, 1996; Kaplan &
Sadock, 1993). The elderly sometimes take extra doses of medication because they forget they had
already taken it. Some physicians may be too quick to inappropriately medicate the elderly for grief
or other psychological conditions, thinking they cannot really do very much for older persons
(Cummings & Cummings, 2000; Hartman-Stein, 1998).
Assessing Substance Abuse

Most psychotherapists are able to identify only about one in ten patients with significant substance
abuse problems (Cummings & Cummings 2000). Because most physicians have received little
education on substance abuse (generally a few hours in most training programs, with little emphasis
on the management of such patients beyond initial detoxification), they are able to identify signifi-
cantly fewer of their substance-abusing patients than psychotherapists (Horst, 1997). The identifica-
tion rate in both psychotherapy and primary care is abysmal (Cummings & Cummings, 2000).
For this reason, and because primary care physicians have neither the time nor the training to
conduct long clinical interviews to screen for substance abuse, a number of screening devices have
been developed in attempts to increase the number of substance abusers identified in primary care
settings. Physicians find some to be too long and cumbersome to use regularly. For example, the
25-item Michigan Alcoholism Screening Test has been studied in primary care practices, but most
physicians find even the briefer versions too cumbersome (Horst, 1997). Other screening devices
are not sensitive enough to identify many substance abusers, resulting in too many false negatives.
For example, the four-question (CAGE) instrument has also been studied in primary care settings,
but research indicates that it fails to identify many alcoholics and most patients who abuse other
substances (Horst, 1997).
When physicians or psychotherapists ask a substance-abusing patient about his or her drug and
alcohol use during clinical interviews, the patient’s denial will invariably cause him or her to grossly
minimize the amount. My own clinical experience suggests that a more accurate assessment can be
obtained by multiplying the patient’s answer by two, four, or even ten (Cummings & Cummings,
2000). Patients will sometimes ask a matter-of-fact question or make a statement (as an aside) that
both hides and discloses the facts. For example, an aside might be, “By the way, doctor, I sometimes
have a shot of whiskey at bedtime to help me sleep.” The physician generally responds, “That’s fine.
One shot of whiskey occasionally at bedtime never hurt anyone.” It may be, however, that the
patient is going to bed with a bottle every night. The patient mentions the “one shot” because he or
she is worried and seeks reassurance. Another patient might ask, “Having a glass of wine with din-
ner is okay, isn’t it?” The physician generally responds to such a question by reassuring the patient
that a glass of wine is fine, not realizing that the patient’s “glass” actually holds 32 or even 64 ounces
of wine. By throwing out the aside and receiving the physician’s response, the patient can reassure
him- or herself, “I told the doctor, and he (or she) doesn’t think I drink too much.”
Interestingly, at least 80% of substance abusing patients will candidly answer questions regard-
ing their drug and alcohol behavior on written questionnaires or scales presented within the health
system. These same patients will lie at least 90% of the time when asked face-to-face about their
drug and alcohol use, and will even contradict their written statements in a face-to-face interview
(Cummings & Cummings, 2000). Most primary care practices include questions on alcohol and
drug use in their medical history forms, which each patient is required to complete. These health
screening devices include such questions as, “Most days I have none, one, two or three, more than
five drinks in a day [indicate number]” or “I use the following recreational drugs,” with choices
after each [never, rarely, occasionally, frequently, regularly]. The numbers reported on such written
questionnaires are far more accurate than those elicited during a face-to-face interview. The patient
answers accurately so that he or she can then reassure him- or herself that the doctor knows the
truth and is not concerned. Amazingly, this is usually the case, as physicians seldom pay much
attention to the drug and alcohol information on the very questionnaire they demand that each
patient complete (Cummings & Cummings, 2000). These same physicians do take into account
information on disease or family medical history revealed on the same questionnaire. The portion
of medical questionnaires dealing with drug and alcohol use provides useful therapeutic informa-
tion to physicians and should not just be treated as filler for the chart.
A number of good screening devices are currently being used in primary care settings. These
include the four-question CAGE instrument (Ewing, 1984), the 25-question Michigan Alcoholism
Screening Test (Selzer, 1971), and the 10-question Alcohol Use Disorders Inventory Test (AUDIT)
(Saunders, Aasland, & Babor, 1993). These and other similar instruments can be helpful in assessing
substance abuse in primary care settings. However, many physicians find the longer instruments
(those with 11 or more questions) to be too lengthy (Horst, 1997). Some primary care practices
have found it helpful to embed the substance-abuse questions within other general medical ques-
tions, rather than on a separate form, to increase the truthfulness of patient responses (Horst, 1997).
Cummings and Cummings (2000) list a number of signposts that can alert the psychotherapist
or physician to the possibility of substance abuse. The patient exhibiting such signs may or may not
be an addict, but it is prudent to explore the possibility. No one signpost is conclusive, but each
serves to raise a red flag. These signs should never be ignored or glossed over, as taking them
seriously will significantly increase the number of substance-abusing patients properly identified.
The signposts most likely to become apparent in a primary care setting are
1. Frequent auto accidents. The injuries sustained often require medical care.
2. Two or more bone fractures in a 3-to-5-year period. The patient may be a falling-down drunk.
3. Spousal battery, physical abuse of children, or both. Men who batter their spouses and beat
their children are usually heavy drinkers or drug users. Since a physician or group practice
may provide medical care to entire families, the medical problems of some family members
may indicate substance abuse on the part of another family member.
4. Tweaking (picking the face or the skin on the forearm). This can be a sign of drug abuse,
particularly in women.
5. Unusual physique. Amphetamine users will be very thin, even emaciated. Some cases of
obesity, particularly a sudden occurrence in a younger patient, may be due to “marijuana
munchies.”
6. Paranoia. Prolonged, heavy use of amphetamines can result in sudden and severe paranoia,
even in patients with no history of psychotic symptoms. The paranoia is often accompanied
by tactile and visual hallucinations. Unlike the auditory hallucinations common to schizo-
phrenics, tactile and visual hallucinations are due to organicity.
7. Stains on clothing, red eyes or nose, sores around the mouth, poor muscle control, and loss of
appetite. These are seen in children who abuse inhalents.
8. Missed adolescence. Many addicts missed going through their own adolescence, and there-
fore have never resolved the adolescent authority struggle. They reject any of life’s demands.
In primary care settings, these patients often present as demanding, argumentative, and
noncompliant with the physician’s recommendations.
Other signposts are commonly seen in mental health settings, but may also be reported on
occasion in primary care settings.
1. DUI (driving under the influence) or DWI (driving while intoxicated).

2. Frequent traffic violations.
3. “I’ve lost everything!” (a frequent complaint among addicts who are upset by the conse-
quences of their addiction but fail to recognize that their addiction has contributed to
their troubles).
4. Amotivational syndrome. Chronic marijuana users eventually lose interest in life. They often
express a general, vague dissatisfaction, but are not really depressed.
Most physicians are, understandably, reluctant to probe for more information on substance use
when they notice reports of high usage on a questionnaire, hear an aside that alerts them to the pos-
sibility of substance abuse, or observe another signpost of substance abuse. In integrated settings,
however, the nurse or physician who first notices a report of heavy substance use on a questionnaire
can alert the behavioral health-care specialist onsite and ask him or her to participate in the patient
interview along with the physician. Should an aside or other signpost become apparent during the
interview, the behavioral health-care specialist can then be brought in. (For detailed interviewing
strategies, the reader is referred to chapter 6, “Establishing a Therapeutic Alliance” and chapter 7,
“Further Interviewing Strategies” in Cummings and Cummings, 2000). Should the discussion
become protracted or should the patient need further substance-abuse assessment or intervention,
the physician can seamlessly leave the patient with the behavioral health-care specialist and con-
tinue tending to other patients.
In carve-out systems, where behavioral health care is not colocated with primary care, the physi-
cian is left with several options when he or she notices a report of high substance usage on a
questionnaire, an aside, or other signpost: (1) ignore the information, (2) attempt to interview the
patient to further assess for substance abuse, even though he or she may have neither the time
nor skills to do so, (3) refer the patient for assessment in a behavioral health-care setting, accepting
the fact that few patients (at most 10–15%) will then present to be assessed in behavioral health
care (Cummings, Cummings, & Johnson, 1997).
Models of Substance Abuse Treatment

Cummings and Cummings (2000) list three treatment models in the field of chemical dependency.
Each makes important contributions to the field, but each has its own inherent limitations. They
are the medical model, the behavioral model, and the abstinence model.
The Medical Model

The medical model asserts a physiologic basis for addiction and further holds that treatment is
medical. In its purest form, this model refuses to acknowledge any psychological basis for addic-
tion, which is always viewed as physiological. The medical model acknowledges the growing body
of evidence regarding the role of genetics in addiction, provides a basis for the tissue changes that
occur with addiction, and explains the phenomenon of tolerance in light of these tissue changes
(Bloom, Lazerson, & Hofstadter, 1985; Carlson, 1986; Murray & Stabenau, 1982).
The medical model has two forms of treatment: withdrawal by substituting another drug and
slow withdrawal by titration. Because the addict is addicted to a class of drugs rather than to just
one member of the class, the substitution approach fails to treat the addiction. Although the abrupt
withdrawal of CNS depressants can result in seizures and other medical complications and must be
titrated, the concept has been extended to withdrawal from drugs in which seizures or other
complications are not a threat. Physicians use titration even when it is medically unnecessary in
order to make withdrawal comfortable, a concept that may actually encourage addiction. Unfortu-
nately, the medical model has contributed to a culture that believes a solution to any problem can
be found in a pill or potion. In turn, the model seems acceptable to many patients in light of the
current culture.
The Behavioral Model

The behavioral model is a psychological approach to addiction treatment that regards addictive
behavior as a learned response (L’Abate, Farrar, & Serritella, 1991; Miller, Smith, & Gold, 1996).
Most psychologists adhere to this model and use cognitive behaviorism and other approaches to
change the set of learned behaviors (or habit patterns) regarded as addiction.
Although addictive behavior is a learned response and the comprehensive treatment of addiction
relies heavily on behavioral therapy, the model is based on an erroneous basic premise. The premise
is that addicts can learn to become social users. Although many substance abusers can control their
use and appear to be social users for a limited period of time, relapse is inevitable (Cummings &
Cummings, 2000).
The Abstinence Model

The abstinence model incorporates the physiological aspects of the medical model with the best
in the behavioral treatment of addiction. It asserts that substance abuse brings about permanent
cellular changes, which constitute the drug tolerance of the addict and make it impossible for the
person to go back to a level of social use. This model is the most used conceptualization of addic-
tion, as it is espoused by Alcoholics Anonymous, Narcotics Anonymous, and other 12-step programs.
It is axiomatic in this model that the highest level of drug tolerance achieved becomes the
minimum daily requirement for that drug. According to this model, the only alternative to a life of
increasing dosage is total abstinence. The model acknowledges that addiction can be predisposed by
genetics, that it is acquired physiologically by use and abuse, and that it can be learned and acquired
through life experiences. However, it avoids futile attempts to weigh the contribution of each
of these factors toward the resulting addiction in a particular individual.
Research has shown that the behavioral and abstinence models are about equally effective
for up to 2 years posttreatment. However, through the 3rd and 4th years, the abstinence model
clearly prevails over the behavioral model (Cummings & Cummings, 2000; Quimette, Finney, &
Moos, 1997).
The critical feature that increases the likelihood of a successfully clean lifestyle is the drugless
detoxification of the patient in which he or she undergoes withdrawal or detoxification without
the use of alternative or substitute medications. For those patients in danger of convulsions, a suffi-
cient dose of the drug is available if necessary. However, the patient is not so advised due to the
likelihood that he or she would bring on a convulsion in order to get the medication. This drugless
detoxification is certainly rough on patients, but they never forget the horrendous discomfort,
which becomes a constant deterrent to recidivism. There is considerable evidence that patients who
are offered relief from the symptoms of withdrawal will experience an escalation of these symptoms
in order to be given the substitute medication (Center for Substance Abuse Treatment, 1997;
Cummings & Cummings, 2000). This has led to an axiom that addicts easily understand: the degree
of pain on withdrawal is directly proportional to the proximity of a sympathetic physician.
The abstinence model does have one intrinsic limitation. The requirement of abstinence is quite
stringent, and it is usually demanded of the addict long before he or she is ready to contemplate a
lifestyle totally free of chemical abuse (Gould, 1999; Narcotics Anonymous Worldwide Services,
1988). In other words, the patient is confronted with the requirement of abstinence in the absence
of sufficient motivation, or long before he or she has hit bottom. Very few patients referred
for substance-abuse treatment have actually hit bottom. Rather, the referrals usually reflect the
exasperation of others in the addicts’ lives. In the medical and behavioral models, the patient
cooperates with treatment because of the belief that treatment will enable him or her to be a social
user. The failure of this type of treatment is evident only after the treatment is concluded and the
patient’s use escalates to the pretreatment level, whereas the demand for abstinence is immediate in
the abstinence model (Gould, 1999; Alcoholics World Services, 1986).
Treatment Strategies That Work
Inpatient Versus Outpatient Care

In the past 15 years, there has developed a multibillion-dollar, for-profit, inpatient-addiction
treatment industry. Addiction treatment has cost employers billions of dollars per year. Even
though employers have balked at paying for the treatment of emotional and mental disorders,
they have in the past been eager to pay for inpatient addiction treatment in anticipation of saving
money in the long run by reducing absenteeism, job injuries, poor productivity, and lawsuits. The
results of expensive inpatient addiction treatment have been most disappointing (Cummings &
Cummings, 2000).
The research overwhelmingly indicates that inpatient treatment of substance abuse is not signif-
icantly more effective than outpatient treatment to the point where this conclusion is inescapable
(Saxe & Goodman, 1988). In the United States, misallocation of resources has led to drastic
overspending to treat addiction. Unfortunately, however, spouses, families, employers, and society
(through its overcrowded courts) are clamoring for inpatient care in order to have someplace to
send the addict. Later these same people complain that hospitalization is too costly in view of its
disappointing results.
The determination to hospitalize a patient should not be based on psychological need, but rather
on two factors: medical necessity and social instability. The need to detoxify in a hospital setting has
often been cited by hospital-based practitioners, but research has clearly demonstrated that the
number of patients needing to do so is much smaller than previously believed (Saxe, Dougherty,
Esty, & Fine, 1983; Saxe & Goodman, 1988). If a patient is in danger of convulsions or other
dangerous medical complications, he or she should be detoxified in a hospital. However, the
decision is usually based on patient comfort or the existence of insurance that will pay for the hos-
pitalization. Even for a patient in danger of medical complications, it is usually feasible to hospital-
ize him or her only briefly, often in a system less intensive than the full hospital. A well-trained
addiction nurse practitioner is present to monitor the patient for prodromal signs of medical
complications for the first 48 to 72 hours, after which the patient is seamlessly transferred to
outpatient care within the same program.
Very skilled psychotherapists are able to successfully employ outpatient drugless detoxification
of most patients, including heroin addicts, by sending them home with a drug-free friend
who babysits them through 72 hours of withdrawal. In such cases, the psychotherapist gives
the “babysitter” about 2 hours of training prior to the detoxification process and telephones the
patient and “babysitter” every 2 or 3 hours, day and night, throughout the withdrawal process
(Cummings, 1979; Cummings & Cummings, 2000). Since less-skilled psychotherapists may not be
equipped to handle their patients’ detoxifications in this manner, the next-best approach is to admit
the patient to a hospital or less-intensive facility for up to 72 hours. The patient is monitored by a
nurse practitioner. The hospital or other facility must agree beforehand, however, that medications
will not be administered to the patient unless a small amount is medically necessary to prevent
medical complications.
As was previously stated, social instability (lack of social support) may be a reason to consider
inpatient treatment for a particular patient. Research has suggested that more severely addicted and
less socially stable patients often do better in either inpatient care or more intensive outpatient
treatment, whereas less severely addicted and more socially stable patients do better in less-
intensive outpatient programs (Saxe, Dougherty, Esty, & Fine, 1983; Saxe & Goodman, 1988).
It is quite common to find patients who have repeatedly failed inpatient programs to go on to
succeed in outpatient treatment (Cummings, 1991). In the hospital, the patient has not given up
the chemical. Rather, the chemical is being temporarily withheld or, worse yet, a substitute chemical
is being administered. Hospitalized patients do not develop the coping skills necessary for success
outside the hospital. On the other hand, the patient who becomes abstinent outside the hospital is
already establishing the skills needed to maintain abstinence (Cummings & Cummings, 2000;
Quimette et al., 1997; Saxe et al., 1983; Saxe & Goodman, 1988).
Intensive Outpatient Programs

The intensive outpatient program (IOP) has been devised to increase patients’ motivation to
seriously consider an abstinent lifestyle as the best solution to addiction. In its ideal form, the IOP
combines the best of outpatient treatment with the intensity of partial residential care. The IOP
typically is several hours of outpatient care daily for a specified number of weeks or for a number of
weeks specifically tailored for each individual case. Patients are required to meet criteria of atten-
dance, abstinence, and family involvement. For most of the severely addicted and socially unstable
patients, the IOP is more effective than hospitalization. It is, however, too intensive for less severely
addicted and more socially stable patients. They will respond better to a fully outpatient program
(Cummings & Cummings, 2000; Quimette, Finney, & Moos, 1997; Saxe et al., 1983; Saxe &
Goodman, 1988).
Preaddictive Group Programs

The preaddictive group is a program developed for patients who are likely substance abusers but
who are not ready to enter an outpatient addiction group or IOP. Like the IOP, the preaddictive
group was devised to increase the patient’s motivation to embrace an abstinent lifestyle. It satisfies
the objection that by going directly into an addictive program the patient is being erroneously
labeled an addict. The program is designed to soften the resistance of addicts who are far from
hitting bottom and who object to an abstinence-based program. The addict who resists referral to
an outpatient addiction group or IOP is invited to join a psychoeducational program and then be
the judge of whether he or she is addicted. The patient is assured that there will be no pressure if
he or she decides not to go into a treatment program. Even more provocatively, the patient can be
challenged, “Why not spend five sessions and prove you are not an addict just like you say?”
The preaddictive group meets for 2 hours daily, usually in the evening to accommodate patients’
work schedules, with five consecutive daily meetings in each series. Follow-up studies indicate a
50% increase in the number of addicts who enter an outpatient addiction treatment program and
a similar increase in the number who complete the program (American Biodyne, 1985–90;
Cummings, 1979). The group also serves to reduce the number of complaints by addicts who are
required to be abstinent (Cummings & Cummings, 2000).
In larger group practices, a preaddictive group can be offered onsite. Patients may be more
willing to attend such a group in the primary care setting than in a separate behavioral health-care
setting (Cummings, Cummings, & Johnson, 1997). However, smaller practices may not have a large
enough patient population to offer such a program onsite. In such cases, a significant number of
patients properly assessed and challenged by a behavioral health-care specialist onsite will attend
the preaddictive group even though they must go to a separate behavioral health-care setting in
order to do so.
Group Versus Individual Therapy

Abstinence-based group treatment for substance abuse is overwhelmingly more effective than indi-
vidual treatment (Cummings, 1991; Cummings & Cummings, 2000) and generally graduates into
recovery about 60% of those who begin (Cummings, 1982; Cummings & Cummings, 2000). The
behavior of substance abusers in their denial resembles that of adolescents more than that of adults.
They tend to be antiauthority (antiparental) and are generally more influenced by peers (fellow
adolescent-like addicts) than by their physician or psychotherapist, who are seen as parent figures.
Patients in a group setting can say things to each other that the therapist could never say, because
the patient would either take umbrage or simply dismiss what the authority figure said. In group
substance-abuse treatment, the role of the therapist is to create a group culture committed to
abstinence and subsequent change of lifestyle. Once such a culture has been created, the milieu
allows patients to challenge and confront each other with a directness that would never be tolerated
from a therapist. Addicts are often able to “con” their physicians and even their psychotherapists,
but rarely can they fool their fellow patients.
A typical successful outpatient addictive group is composed of 10 to 12 patients who have all
undergone withdrawal and are abstinent (Cummings, 1982; Cummings & Cummings 2000).
The patients are addicted to various substances, as this variety helps to emphasize the nature of
addiction: an addict is not defined by what he or she ingests, shoots, or inhales but by his or her
lifestyle. This type of mixed group may be particularly eye-opening for the patient addicted to
prescription medications. Such a patient may self-righteously believe that he or she is not a real
addict, and finding him- or herself in a group program alongside patients addicted to hard-core
street drugs may cut through a patient’s strong denial.
The group meets once a week for 2 hours, usually in the evening because it is a requirement that
patients return to work as soon as possible. The program can take place in the primary care setting
or separate behavioral health-care setting. All group members start on the same first session, and
once the group begins no one else is allowed to join. The program lasts 20 weeks, during which
time the patient has recourse to five individual sessions, but only in response to need. Thus, the
approach allows for individual attention in a severe crisis, without detracting from the group
process. Attendance and abstinence are both required. At the beginning of each session, each
patient is asked whether he or she has remained sober since the last session. Any patient that has
not remained sober is assigned a “fall.” A fall is also assigned to any patient who was absent from
the previous session, and whose absence the group votes to be unexcused. Patients receiving a fall
for failing to maintain sobriety are required to leave and forfeit the remainder of the session. Each
patient is allowed three falls, and on the fourth fall the patient has failed the program and is
excluded from the group (Cummings, 1982; Cummings & Cummings, 2000).
Aftercare
Addiction cannot be cured, although recovery is possible. Therefore, most addicts who complete
an addiction treatment program need to continue in some type of aftercare in order to maintain
sobriety. Although some substance-abuse programs offer an aftercare program, many utilize
12-step programs available in most communities for aftercare. Addicts can be encouraged to join
12-step programs while in the IOP or other outpatient addiction treatment program. On comple-
tion of the program, they can be encouraged to continue in their 12-step program for as long
as necessary.
Countering Resistance and Motivating the Patient for Appropriate Treatment

The difficulty in treating substance abuse using the abstinence model is that there are great individ-
ual differences in what constitutes “bottom” (a set of adverse circumstances under which an addict
is motivated to give up his or her addiction), and some addicts do not have a bottom. Furthermore,
the physician may assess substance abuse in a patient long before that patient has hit bottom. He
or she must then refer the patient to an appropriate behavioral health-care specialist long before the
patient would be motivated to seek such treatment. The behavioral health-care specialist must
in turn encourage the patient to enter a treatment program that requires a commitment to
abstinence when the patient still believes he or she can become a social drinker (Cummings &
Cummings, 2000).
There are a number of techniques a skilled behavioral health-care provider can use to increase
the patient’s motivation for appropriate treatment. In integrated systems, the physician should
involve the behavioral health-care specialist in the treatment of the patient suspected of being an
addict. In a carve-in or fully integrated system, the physician can introduce the patient to his or her
“colleague,” the behavioral health-care specialist in the office, for a seamless transition with nearly
100% of patients having at least a brief initial encounter with the behavioral health-care specialist.
In a carve-out system, the physician must refer the patient to a separate location in order to see the
behavioral health-care professional. In such a case, only about 10% of patients referred will actually
present (Cummings et al., 1997).
Some of the techniques that skilled behavioral health-care providers use to motivate addicted
patients are paradoxical and may look uncompassionate or be otherwise misunderstood by
the untrained observer. Even though most physicians will never be called upon to deliver such
interventions, it is imperative that they become familiar with the basic types of paradoxical inter-
ventions used in order to avoid becoming alarmed at seeing the interventions implemented and
inadvertently sabotaging the efforts of the behavioral health-care provider. Physicians can receive
this level of training in brief (1 or 2 hours) in-service programs. At the very least, physician training
should emphasize that successfully motivating the patient rests on two important therapeutic prin-
ciples of addiction: (1) the addicted patient is not really ready to change even if he or she asks for
substance abuse treatment; (2) the secret to reaching the patient is through the obstinacy that is
part and parcel of the addict’s denial. A brief description of the major interventions for reaching the
patient through his or her obstinacy, outlined by Cummings and Cummings (2000), follows.
The Preaddictive Group

The preaddictive group, described previously in this chapter, is a means for reducing the resistance
of addicts with very intense denial about their addiction. Information on addiction will be
presented, and the addict can decide for him- or herself whether it applies. Attending the preaddic-
tive group increases the addict’s chance of entering the addiction program by 50% (American
Biodyne, 1985–90). Once he or she has entered the addiction program, the addict has a 50% greater
chance of successfully completing the program (American Biodyne, 1985–90).
Axioms
Another way of countering the denial of the patient who is not ready to consider a life of abstinence
is by strategic paradoxical interventions termed “axioms.” Twelve-step programs use a number of
axioms, which are readily understandable to the addict. For example, 12-step participants who try
to justify ongoing substance abuse by saying they have a “disease” will often hear their fellow
addicts say in unison, “You are not responsible for your disease, but you are responsible for your
recovery.” Axioms can also be used when interviewing or treating addicts in medical or mental
health settings. For example, when a highly resistant patient demands a practitioner who will
provide a substitute drug to ease the ordeal of withdrawal, such a referral is offered, along with the
axiom that “the degree of pain on withdrawal is directly proportional to the availability of pain
killers.” As another example, when a resistant patient insists that he or she will be able to dry out
once there has been sufficient psychoanalysis, the skilled therapist offers an axiom by asking the
patient if he or she has noticed that “all insight is soluble in alcohol and drugs.”
The Challenge
Many of our addicted patients will vehemently deny that they are addicted. Others will admit to
their addiction and express the sincere desire to quit. However, once this addict sees some success in
convincing the psychotherapist of sincere intent, denial takes over once again. The psychotherapist
is quick to reassure the pleading patient that all will be well because the patient really wants to get
well, and this reassurance results in the patient’s concluding that all is well right now.
A preferable alternative is to challenge the patient’s sincerity, and this must be done firmly,
resolutely, and consistently. The therapist plays “devil’s advocate” and gives the patient reasons why
he or she really does not want or need to quit. In response, the patient generally will counter the
therapist’s points with reasons that he or she really does need to quit. Then, the therapist challenges
the patient’s ability to quit for a specified period of time (which is generally the longest interval of
sobriety that the patient has experienced in the past 6 months).
When the patient returns after the specified period of sobriety, the therapist challenges the
patient’s willingness and ability to sustain sobriety long term. The patient will generally argue that
he or she is indeed willing and able. The therapist then suggests that the patient prove it by entering
an addiction group or IOP. (For a more detailed discussion of “The Challenge,” the reader is
referred to chapter 6, “Establishing the Therapeutic Alliance,” in Cummings and Cummings, 2000.)
Even if the patient’s intentions seem nefarious at this point, he or she is going to spend 20 weeks in
a firm, continuously challenging, and successful program based on abstinence. The longer the
patient is abstinent, the greater the inroad of therapy.
A Variation of the Challenge

It is sometimes possible to elicit a long-lost wish from the patient and then to reignite it in the
service of motivating him or her. This wish can be almost anything, such as the ambition to obtain
a college degree or return to the pursuit of a career that was long-ago abandoned, or the desire to be
reunited with one’s children. At this point, the therapist gives an example of a former patient
(or two) who had just such a longing and who, by cleaning up, fulfilled the desire. Then, just as the
patient begins to show excitement at the prospect, the therapist becomes discouraging, focusing on
the patient’s degree of addiction and lack of desire to give up the chemical dependency. As in the
previously described challenge, the patient insists that it is possible to try. The therapist can then
go into the standard challenge, “Well, I’m not convinced. But there is a way that would prove
me wrong.”
“You’re Not an Addict”

Patients try to convince their physicians and psychotherapists that they are not addicted. After
establishing the necessary rapport and therapeutic alliance with the patient, the therapist can begin
this paradoxical strategy when the patient resorts to denial. Consider the following example:
Patient: My wife is threatening to leave me. I’ve got to get off the dope.
Therapist: How many times has she threatened to leave? She always comes back to you when
you’ve laid off for a while. This is no different.
Patient: No. She really means it this time. She says I neglect her and the kids, and she’s had
enough.
Therapist: Don’t give up so easily. Let’s spend a little time figuring out how you might con her
again. Just think of what you’re saying, that you’ll give up drinking forever. No way!
Patient: No. I don’t think it would work. I think it’s time to really shape up.
Mobilizing Rage to Support Health

Rage is the most galvanizing emotion in the human experience. Although love may be the greater
emotion in the long run, rage is immediate and directed (Cummings & Sayama, 1995; Fromm-
Reichman, 1950). Addicts generally have trouble with hostility. Although many are mild, lovable
people when sober, many become hostile and mean when stoned or drunk. The previous examples
have shown how a therapist can skillfully mobilize the patient’s rage against the therapist, but in
the direction of a healthy outcome. The mobilization of rage in the interest of health enables the
therapist to cut through a wall of denial that otherwise would be impenetrable (Cummings &
Cummings, 2000).
Leveraging the Blackout

It is important to ask whether the patient has experienced blackouts. If not asked, the patient will
not think to mention it because his or her denial has already relegated the blackouts to the realm of
insignificance. In fact, blackouts are extremely important because they are an early sign of brain
damage (Lezak, 1983).
Patients are horrified to be told that the blackout is early alcoholic brain damage. The therapist
can use this knowledge to increase the patient’s motivation, but only indirectly. As soon as
the patient begins getting over the realization that his or her brain has been damaged, denial kicks
in to minimize the importance of the damage. At this point, the therapist can begin a paradoxical
strategy by impressing on the patient that the brain damage is irreversible and progressive, and at
the same time grossly minimizing the importance of the central nervous system involvement
for him or her.
The therapist may then state that there are great individual differences, and the patient may be
one who is only slightly affected. The patient will generally protest that he or she does not want to
take that chance because one in two odds are not very good and he or she needs all his or her brain
cells. From here, the therapist expresses doubt as to the patient’s sincerity and leads him or her
through the challenge.
This particular intervention lends itself especially well for use in an integrated primary care
setting with a physician and a behavioral health-care specialist working together. The physician can
explain the physiological basis for blackouts, thus giving credence to the behavioral health-care
specialist’s strategic intervention.
Challenging the Group

During the first session of the 20-session substance-abuse group program, the therapist tells the
group that the ideal group size is eight patients, but that ten have been accepted because two will
flunk out. (If twelve have been accepted, then the expectation is given that four will fail.) This is a
challenge that no addict can resist: to show the therapist and the rest of the group that he or she will
not be the one who flunks out of the group.
Confronting the Games

There are a number of behaviors stemming from the addict’s denial that are so consistent and
enduring that they have been termed “the games” (Berne, 1964; Cummings & Cummings, 2000).
The games are simply derivatives of denial or, in other words, the vehicles through which denial
operates. It is helpful to assign names to each of the 11 games to provide a shorthand for confront-
ing the addict during the group process in the addiction group. It is helpful for the physician or
psychotherapist to become familiar with these games, as recognizing them in patients will increase
the practitioner’s ability to recognize the substance-abusing patient.
The Woe-Is-Me Game. The woe-is-me game is a form of self-pity that the patient’s denial has
adopted in the service of the addiction. The patient rationalizes his or her addiction, believing he or
she has been driven to addiction by life’s unfortunate circumstances. This game is used as an excuse
to resume alcohol and drug activity after a brief period of sobriety. For example, an addict may
rationalize a relapse because he or she was denied a promotion at work, because his or her car broke
down, or because of a nagging spouse.
The Victim Game. This is similar to the woe-is-me game, except that the addict sees the cause of
his or her addiction as stemming from a more permanent or pervasive source than the sudden
annoyances that beset everyone. For example, the addict may rationalize his or her addiction
because he or she grew up in poverty. It is important for the physician or psychotherapist to
remember that the majority of persons growing up in such circumstances do not become addicts,
and that there is a significant percentage of those growing up with privilege that do become
addicted.
The Rescue Game. The addict spends a great deal of time rescuing anyone and everyone else who
may want help. The more unworthy the prospective recipient the greater the likelihood the addict
will expend energy to rescue that person. Because the addict believes in some kind of magical score-
keeping, he or she behaves as though there were a depository of owed rescues. The belief is that
when he or she requires rescuing, no matter how much he or she has messed up, someone will ride
to the rescue.
The Blame Game. The blame game differs from the victim game in that the addict holds someone
else directly responsible for an unfortunate event that happened. For example, if a diagnostic
workup shows chronic pancreatitis, the addict will blame poor medical care, not chemical dependency.
The Feeling Game. The addict is adroit at counterfeiting feelings such as genuine understanding
and contrition. Tears of remorse are common, yet the remorse quickly disappears as the addict then
plunges into defending his or her behavior. Because chronic inebriation breeds irritability and a
short temper, not warmth and kindness, be wary of the patient who presents as just too wonderful.
His or her family or coworkers may present a completely different picture.
The Insight Game. Addicts enjoy talking about everything in their lives except their addictions,
showing impressive insights, yet continuing their addictive behavior. The physician or psychothera-
pist must avoid being seduced by such a patient’s “insight,” remembering that it is meaningless in
light of continued substance abuse.
The Rubber Yardstick Game. The rubber yardstick game is used by the addict to measure his or
her substance abuse. The addict may greatly underestimate the amount of drugs or alcohol used,
or may greatly overestimate the period of sobriety. A frequently overlooked manifestation of the
rubber yardstick game, particularly pertinent to primary care settings, is seen in the patient who is
purposely seeing multiple physicians and obtaining prescriptions from each for the drug to which
he or she is addicted. The patient may be seeing five or even as many as ten doctors, but on inquiry
will recall only two or at most three.
The Vending Machine Game. The addict believes that if he or she puts enough coins in the vend-
ing machine (e.g., stays clean for 2 months), then the desired item will automatically be dispensed
(e.g., the estranged spouse will return).
The File Card Game. The file card game is a mnemonic device, but the addict sets it up and uses it
unconsciously. The patient decides that if a certain thing happens, he or she has the right to resume
substance abuse. Once he or she has determined what this crucial thing is, the addict develops
amnesia with regard to this decision.
The Musical Chairs Game. Addicts sometimes try to beat the consequences of their substance
abuse by switching among comparable drugs (those in the same class). When the original sub-
stance produces side effects, interpersonal problems, or legal problems, the addict invokes the same
high from another drug to continue the addiction. Alcoholics playing the musical chairs game
will generally seek prescription central nervous system depressants from their physicians. They
think, for example, that they can remain high yet avoid having their substance abuse detected on a
breathalizer test.
The Special Person Game. Down deep inside, all addicts believe that they are special persons
and that some day this fact will manifest itself to the world. This game may seem innocuous, but
really is dangerous in that it perpetuates the addictive lifestyle. As long as the addict believes that
any day now the special person will make his or her appearance, it is not important to change the
addictive behavior.
Physicians who learn to adeptly recognize these games in their patients will greatly increase the
number of appropriate referrals made to behavioral health-care specialists for further assessment of
substance abuse. Further, such physicians will be significantly less likely to become well-meaning
“pushers” who inadvertently perpetuate their patients’ addictions.
Summary
Even though most physicians will not readily be able to properly identify all their substance abusing
patients, they will likely be able to identify many of them. With practice in the assessment skills pre-
sented here, physicians can become increasingly adept at spotting the red flags that indicate the
possibility of substance abuse so that they can appropriately refer these patients to a behavioral
health-care specialist. Needless to say, the onsite behavioral health-care specialist must be an indi-
vidual who is quite adept at identifying substance-abusing patients and very skilled at implement-
ing the interventions outlined in this chapter.
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Chapter 8
Identifying and Treating the Somatizer:
Integrated Care’s Penultimate
Behavioral Intervention
NICHOLAS A. CUMMINGS
Those few health-care delivery systems that are striving to integrate behavioral health into primary
care tend to approach the task in a piecemeal fashion. Usually one, and sometimes two protocols
are parachuted into an otherwise conventional delivery system, yielding disappointing results. Most
frequently a single disease management program (e.g., diabetes, asthma, rheumatoid arthritis) is
partially infused into the delivery system, and it has as much impact on the total system as one drop
of red dye in a five-gallon bucket of white paint. A favorite single program is a depression protocol,
ostensibly justified because as many as a third or more of primary care patients reveal some level of
depression (Strosahl, Baker, Braddick, Stuart, & Handley, 1997). A truly integrated program is a
complex of seamless behavioral interventions comprising an indistinguishable part of a multifac-
eted health-care delivery system (Cummings, 1997; Strosahl, 1997). The possible effective exception
to the single program approach is that of identifying and treating the somatizer. Because of the
remarkably skewing effect somatization has on a health-care system, its alleviation has an equally
remarkable positive impact. This positive effect has been demonstrated in such extensive demon-
stration/research projects as the 20-year Kaiser Permanente experience (Cummings & VandenBos,
1981) and the 7-year Hawaii Medicaid project (Cummings, Dorken, Pallak & Henke, 1993).
A description of how such a program works is important, as it is potentially the most rewarding
single beginning in an otherwise conventional (nonintegrated) delivery system. A caveat must be
noted, however; in spite of its rewards it does not replace or even approach the potential effective-
ness of a fully integrated system.
Historical Perspective
Somatization was identified in the late 1950s at Kaiser Permanente where it was discovered that
60% of physician visits were by patients who either manifested no diagnosable physical illness that
would account for their symptoms, or whose chronic illness was exacerbated by psychological
factors (Cummings & VandenBos, 1981). In that era the relationship between stress and physical
symptoms was not clearly understood, and the patients for whom no medical diagnosis could be
161
determined were identified in their medical charts as hypochondriacs. Being capitated they did not
have to submit a diagnosis on a reimbursement claim, so Kaiser Permanente physicians had no
necessity to render a provisional diagnosis when no definitive diagnosis could be found. This was
the origin of the diagnosis of hypochondriac, believed to constitute a reflection of absence of
physical disease. When I joined the staff of Kaiser Permanente in San Francisco in the late 1950s,
I found the term to be pejorative at best. It implied that the patient was at fault, doing something
purposely to cause his or her own misery, as well as that of the overworked and baffled physician.
Since physicians were trained to persevere in looking for an organic cause to the symptoms, labora-
tory work, x-rays, electrocardiograms, and other tests were repeated ad infinitum, imposing a
financial strain on the medical system along with the strain stemming from physician overload.
Furthermore, since the Kaiser Permanente physicians were capitated, as opposed to fee-for-service,
the high utilizers of health care added no revenue and deflected the overworked physician from
time that might be devoted to the seriously medically ill. These severe strains on the medical system
are what prompted Kaiser Permanente to create a mental health department that would address
the issue. It must be noted that this was during a period when no insurer or third-party payer
included psychotherapy as a covered benefit. To incorporate psychotherapy within the medical care
system was a radical step, indeed, and one that eventually led to the inclusion of psychotherapy not
only at Kaiser Permanente, but also in indemnity health insurance in general (Cummings &
VandenBos, 1981).
Several methods were used at Kaiser Permanente to identify and treat the overutilizers of medi-
cal care, but first it was necessary to purge the system of the concept of hypochondria. I tried a
number of substitutes, all of which were rejected, until at a late-night brainstorming session
I suggested that these patients were somaticizing stress, and could be referred to as somaticizers.
Both Drs. Sidney Garfield and Morris Collen, cofounders of Kaiser Permanente, liked the terms,
suggesting they sounded medical enough to be acceptable to the physicians. Thus were born the
terms, which later were shortened by grammarians to somatizing and somatizers, and ended use of
the offensive term hypochondria as standard diagnostic label in medical charts.
Recently some health psychologists have begun using the term “somatically focused patient,”
believing this to be more politically acceptable because somatizer is a pejorative term among
physicians. Experience has shown that physicians are not hostile toward somatizers, but baffled as
to how to manage these patients who require so much of their time and do not respond to medical
attention. When a colocated behavioral care provider is available, however, physicians reveal their
interest and intense concern for the somatizer. The substitution of an ostensibly more politically
correct term that physicians would find awkward and unusable provides a verbal varnish at best,
and does not begin to address the real problem of population management that requires the imple-
mentation of integrated care.
Several years after a system of triage for the somatizers had been in operation, there emerged a
series of studies that established the impressive reduction in medical overutilization through brief,
focused behavioral interventions (Cummings & Follette, 1968; Cummings, Kahn, & Sparkman,
1962; Follette & Cummings, 1967). These studies captured the attention of the National Institute
of Mental Health (NIMH), and a series of two dozen replications emerged within a decade
(Jones & Vischi, 1979). In all but one study the savings in medical costs far exceeded the cost of
providing the behavioral services, and the NIMH dubbed the phenomenon as the “medical cost
offset” effect. A subsequent consensus conference attended by all the researchers in medical cost
offset indicated that the effect was present only in organized systems of care that had the capacity to
identify and treat the somatizer, and it was not present in solo-practice, fee-for-service settings
where the somatizers increased revenue and thus removed any incentive to address medical
overutilization. (These findings are discussed in the Results section below.) Suffice it to say that the
Identifying and Treating the Somatizer • 163
insurance community and the federal government were impressed enough to begin considering
psychotherapy as a covered benefit.
The Definition of Somatization

Somatization is simply the translation into physical symptoms of any psychological stress, emo-
tional distress, or conflicts in living. In this way the source of the original stress is masked and not
immediately identifiable by the physician who regards physical symptoms as indicative of medical
illness. It has nothing to do with the diagnostic category of somatization disorder, introduced by
the American Psychiatric Association into the Diagnostic and Statistical Manual (DSM-IV) many
years after the original term was coined at Kaiser Permanente (American Psychiatric Association,
1994). In the so-called somatization disorder the patient manifests symptoms from at least three of
several categories, reminiscent of choosing a Chinese dinner with two dishes from column A, three
from column B, and one from column C. In half a century of practice I have seen less than a half-
dozen patients who would qualify for this esoteric diagnosis, and these were eventually rediagnosed
as latent schizophrenics who were defending against the disintegration of their thought disorder by
a plethora of somatizations, somewhat akin to the manner persons with Munchausen syndrome
manifest symptoms to obtain medical procedures, particularly extensive surgery.
There exists a plethora of models as how stress is translated into physical symptoms. Among
these are alexithymia, the inability to verbalize emotions (Peter Sifneos), displacement of uncon-
scious conflict (Sigmund Freud), culturally determined idioms of distress, operant conditioning
(B. F. Skinner), learned behaviors (Aaron Beck), and many others. All of these are pertinent,
but beyond the scope of this chapter, which is constrained to present the utility, outreach, and
methodology (i.e., the nuts and bolts, not the theory) of directly addressing somatization once it
has occurred.
Data From the Hawaii Medicaid Project

Under the auspices of the Health Care Financing Administration (HCFA), 36,000 Medicaid-eligible
recipients and 90,000 federal employees on the Island of Oahu (Honolulu) were randomized into a
control group (receiving the Medicaid/federal employees’ mental health benefit through privately
practicing psychiatrists and psychologists) and an experimental group. The latter received all
behavioral care through a new delivery system known as the Biodyne Centers, created jointly by the
state of Hawaii and the Foundation for Behavioral Health, specifically for this research project.
The Biodyne Centers provided all mental health services for the experimental group, but made
extensive use of the focused, targeted interventions known as focused, intermittent psychotherapy
throughout the life cycle (Cummings & Sayama, 1995). The control group was eligible for 52 ses-
sions of individual psychotherapy a year with a practitioner of their choice in the community, and
these 52 sessions were renewable annually. In addition, the Biodyne Centers outreached (using the
method described below) each month the 15% highest utilizers of medical care by frequency of ser-
vices, not by total dollar amount. The project permitted further delineation of the patients into
those who had psychological problems only, those who had chronic medical conditions (asthma,
diabetes, emphysema, hypertension, ischemic heart disease, and rheumatoid arthritis), and those
who manifested substance-abuse problems.
The Hawaii project for the first time compared organized mental health care employing targeted
interventions with the far less effective and apparently inefficient solo practice, fee-for-service
psychotherapy model (Cummings, 1997; Cummings et al., 1993). (These results are discussed in
the Results section below.)
The Essence of Medical Cost Offset

Although there is tremendous pressure in the current health-care economy to save dollars, medical
cost offset is not about money. It is about effective care. First, for care to be effective, it must be the
right care. No amount of medical overutilization will bring relief to the patient if it is inappropriate
care. The patient is reflecting psychological, not medical, problems and needs to be treated by effec-
tive behavioral interventions. Redundant medical tests only reinforce the patient’s notion that his or
her condition is medical, and all that is needed is another series of tests to establish this. But the
research also demonstrates that not all behavioral interventions are effective, and somatization is
reduced only by appropriate care. The appropriate care is effective care, and effective care saves
money. But more important than medical savings is the amelioration of the patient’s suffering.
Often this suffering has existed for years because the real (behavioral) condition has not been
addressed by either the medical system or the traditional psychological system.
It is to the description of one such system, the identification and treatment of the somatizer, that
we now turn. It is emphasized that this falls short of a system in which behavioral health and
primary care are fully integrated, but it is a rewarding beginning because it addresses the largest
unnecessary drain on the medical system and is in contrast to the usual one or two programs within
a traditional health-care model that have yielded disappointing results.
The Model
Outreach
There are two approaches to the computer selection of the somatizer. In each, 15% of the highest
utilizers of health care are selected by frequency of visits, not by dollar amounts expended. The
somatizer is identified by constantly seeking medical services, regularly through a large number of
repeat visits, but when these are not sufficient, often through nonappointment (drop-in) clinics or,
if these are not available, through recourse to emergency rooms. Selecting high utilizers by dollar
amount, on the other hand, merely elicits the organ transplants and other costly medical heroics,
patients who are not necessarily somatizers.
Outreach Method 1 was the earliest approach employed. It was more cumbersome because it
sought to acknowledge medical prerogatives and the preeminence of the physician in the referral
process. After eliciting 15% of the highest utilizers by frequency, these patients’ names were sent to
their respective physicians accompanied by a request that the physician consider referring them for
psychotherapy, or behavioral intervention. What was termed a “consider rule” was used in lieu of
advising the physician to refer, or what is known among the various medical specialties in collabo-
rating with each other as an “advice rule.” Because this was the earliest approach to the triage of the
somatizer, utmost care was taken so it would not appear as if the computer were advising
the physician. Along with attention to these professional sensitivities, there was extensive training
of the primary care physicians with strong apparent “buy-in” to the procedure.
The patients were randomized, with the experimental condition receiving the consider rule,
while the control condition became the existing collaboration with behavioral care specialists by
physicians who had received extensive training in identifying behavioral problems in their patients.
The results were disappointing in that the computer consider rule did not elicit any more referrals
than did the usual primary care practice (Cummings & Follette, 1968). The results were interpreted
that in a system in which primary care physicians (PCPs) are optimally referring behavior prob-
lems, the addition of a computer-generated consider rule did not increase referrals. Both methods
resulted in referral of less than 40% of those who would be identified as somatizers by tabulating
15% of the highest utilizers resulting from frequency of visits.
On reconsideration, the elicitation of only 40% of the somatizers, either directly by the PCPs or
through computer prompting, was far from optimal. The research was redesigned so there was even
more extensive training of the PCPs. This included the validation of 38 criteria of distress derived
from the PCPs’ own work samples as recorded by them in their patients’ charts, and without recog-
nizing that these were, indeed, signs that these patients were somatizers. These chart samples were
also validated into those that scored either 3 or 2 points, while most received a score of 1. A score of
9 or more indicated sufficient emotional distress to warrant behavioral care interventions. By
accompanying the computer consent rule with each individual patient’s score on these quickly
recognizable work samples, the physicians could immediately identify with the need for referral.
The number of referrals in the experimental group increased by 50% to almost 60% of the possible
number, while the control group declined to 35% (Cummings, 1977; Cummings & Follette, 1976).
The PCPs uniformly expressed professional comfort in referring these patients, and often followed
with the addendum, “I always knew there was something psychologically wrong with this patient.”
This latter response to our referring physician survey made us uncomfortable and prompted
further research the following year that was not published for several years after its completion
(Cummings, 1985).
A group of 10,667 patients were assessed with the Neuromental Questionnaire (NMQ) and the
38 criteria of distress in a 6-month period in an automated multiphasic health screening. Both the
NMQ and the Kaiser automated multiphasic health screening employing 29 computer leads testing
various medical functions (e.g., blood sugar, electrocardiogram, blood pressure, vital lung capacity,
and so forth, along with the NMQ) in a 2-hour assembly-line procedure have been extensively
reported (see, for example, Friedman, Ury, Klatsky, & Siegelaub, 1974), and will not be repeated
here. Suffice it to say that there was a follow-up over a 6-month period of missed medical diagnoses
by the same 34 PCPs for their patients and for whom they received the consider rule (experimental
group) versus those for whom they did not (control group). The experimental patients were
randomly divided further into three subgroups: (1) those patients for whom the PCP received only
a cryptic consider rule stating, “The patient may have significant emotional distress; consider a
referral to a psychologist,” (2) those patients for whom the PCP received, along with the consider
rule, a paragraph describing somewhat the nature of their emotional distress, and (3) those patients
for whom the PCP received not only the consider rule, but also a two-page computer-generated
description of the patient based on his or her NMQ results. It was anticipated that increasing levels
of psychological information would correspondingly increase the comfort level and incentive for
the PCPs to refer for behavioral care.
In this study (Cummings, 1985), there was a tabulation of the number of symptoms initially
ascribed by the physician to emotional distress that were later (within 6 months) rediagnosed as
physical illness. Using the control group as the baseline for the number of missed diagnoses of
physical illness, it was found that the number of missed diagnoses increased significantly in propor-
tion to the amount of psychological assessment information rendered to the PCP. It was as if the
increasing amount of information not only increased the likelihood of psychological referral, but it
also increased the likelihood that physical illness would be overlooked in a population that was
labeled as having emotional distress.
The function of computer-based elicitation of somatization is to enhance the quality of care and
ensure that individuals who translate emotional distress into physical symptoms receive the behav-
ioral care they need. Researchers may be meticulous in establishing the validity and reliability of
computer-based programs, in this case the NMQ and the 38 criteria of distress, but it is important
that “treatment validity,” or the effect on a delivery system, also be established. Efforts to address
medical prerogatives and sensitivities backfired and led to the discontinuance of having the PCPs
serve as intermediaries in the computer referral to behavioral care of the 15% of highest utilizers (as
defined by the number of physician visits per year).
Outreach Method 2 was employed in the aforementioned 7-year Hawaii-HCFA-Medicaid study
with considerable success and without the limitations and difficulties experienced in the use of
Outreach Method 1. It is the method recommended unless political or sensitivity problems plague
the relationship of PCPs to behavioral care providers. In those instances Method 1 may be the only
consideration, but it should be undertaken with the knowledge that results will be limited and even
complicated by the cumbersome involvement of PCPs as middle step in the referral procedure. For
the use of Method 2 the setting should meet the criterion of PCP willingness to be informed after
the elicitation, referral, outreach, and initial behavioral intervention have all occurred. A slight
modification of Method 2 may be communication to the PCP after the step of outreach and before
the initial behavioral intervention. In all instances, PCP approval and cooperation are vital in the
success of Method 2, with the ultimate aim being collaboration with the PCP in the care of
the somatizer.
Method 2 simply elicits the 15% of patients within a health system that account for the highest
utilization of services by physician visits, not dollar amount. This presupposes that the health plan
has the electronic information systems in place where this is easily accomplished, something that is
far from always the case. The informatics age has been upon us now for over two decades, and the
fact that most health delivery systems do not have in place sufficient medical informatics (MI) tech-
nology attests to the snail’s pace at which health care typically progresses. It is especially troubling
to me, who in working at Kaiser Permanente was able to readily access this kind of information as
early as the mid-1960s.
Elicitation of the 15% highest utilizers is done monthly, and the patients are contacted by a well-
trained outreach worker, usually a nurse practitioner, by telephone. A medical social worker pos-
sessing the same skills and knowledge is an acceptable substitute for the nurse practitioner.
The patient’s belief that her or his condition is caused by physical illness is never challenged. Rather,
the outreach worker empathizes with the patient, “Someone who has had as much illness as you
have had certainly must be upset about it.” This statement usually elicits an immediate reaction,
ranging from an exposition of symptoms to the complaint that physicians don’t seem to understand
or to be sympathetic to the patient’s plight. After hearing the patient out sufficiently to permit
the development of some initial trust, the patient is invited in to explore how the health system
might be of help. The service is free, and perhaps there can be an investigation of the possibility
of alternative treatments to those that have not seemed to work; or perhaps the patient, once the
difficulty is better appraised, may be put in touch with a more sympathetic physician. Then an ini-
tial appointment is made. The entire process has been between patient and outreach worker, with
an initial appointment made directly with a psychologist without the cumbersome and often
discouraging intervening step of conveying the patients’ names to their physicians who then may or
may not refer. The well-meaning physician who does refer may do so with far less finesse than an
outreach worker, often inadvertently challenging the patient’s somatizing.
In contrast, Method 2 successfully elicits initial appointments with most of the high utilizers
who are outreached. It should not be surprising that offering a high utilizer another appointment
with still another doctor (this time a psychologist) is readily accepted, especially when it is accom-
panied by such an empathic attitude. This method was not only used in the Hawaii project, but was
also used with considerable success at American Biodyne, a practitioner-driven, national managed,
behavioral health-care organization (MBHO) from 1985 to 1992, after which the company changed
hands and much of the clinical focus was abandoned by the business interests that constituted the
new ownership. Outreach Method 2 has been extensively described by Cummings and Bragman
(1988) and will not be delineated further here.
Extreme Outreach
The telephone outreach is but one approach used to bring the somaticizing patient into therapy. In
both the Hawaii project and at American Biodyne, there were periodic mailings of brochures and
newsletters to remind these high utilizers of the services offered. Additionally, the monthly newslet-
ter highlighted a specific somatic complaint in each issue, emphasizing the physician’s inability to
help the patient, and again carefully avoiding challenging the patient’s conviction that the condition
is a physical malady.
In spite of all efforts, 8–10% of those outreached consistently resisted making the initial appoint-
ment. A house call seemed indicated, but a psychologist or outreach worker showing up at the door
was invariably refused entrance. A number of approaches were attempted without success, until we
stumbled upon a unique one. A nurse appearing at the door in full regalia, which included cap,
nurse’s gown, cape, and black bag, was not refused admittance to the home even once. She then
typically conducted an interview around the kitchen table, usually with the entire family gathered,
that resulted in the initial appointment being accepted by the somatizer. What was termed extreme
outreach succeeded over time in bringing in, for at least the initial interview, a remarkable 96.3% of
the high utilizers outreached (Cummings & Bragman, 1988).
The Treatment
Assignment of Treatment
One of the primary tasks of the initial appointment with the high utilizer is matching the patient’s
condition with the appropriate treatment. Within the 15% highest utilizers every conceivable
psychological condition will be found, requiring a menu consisting of a large number of targeted
and focused interventions. It is the task of the psychologist conducting the initial interview to
(1) arrive at which treatment would most benefit each patient, and (2) motivate the patient to enter
that program. In the delivery systems Kaiser Permanente, Hawaii project, and American Biodyne as
reported here, there were ultimately 68 program protocols available. Most of the protocols were
psychoeducational treatment group programs, and experience demonstrated that the psychothera-
pist’s time in this kind of delivery system is divided 50% for these psychoeducational groups, 25%
in time-limited groups, and only 25% in individual time-sensitive therapy. Considering that the
group programs had 5 to 12 patients in each, it is apparent that as many as 90% of the 15% highest
utilizers seen would enter a group, rather than an individual treatment program.
A majority of the patients outreached demonstrate some modicum of depression, reflecting a
response to their “physical” symptoms with understandable emotional distress. This does not mean
that all these patients should be assigned to depression treatment; rather, the depression protocols
should be restricted to those manifesting primarily depression, or whose depression is debilitating
enough to be the center of focus. Addressing the depression that might accompany the primary
psychological condition is a part of all 68 protocols. Another significant portion of these high utiliz-
ers will manifest substance-abuse problems. Addicts are high utilizers, ranging from the frequent
injuries of “falling down drunks” to the persistent diagnosis of nasopharyngitis for those who snort
cocaine. It is important to motivate the substance abuser to enter a chemical dependency program,
and this may require several individual appointments. In fact, the number of individual initial ses-
sions required to successfully assign the patient to the right treatment modality is bimodal, in that
both one and three sessions are equal in number.
Offering a somatizer another health-care service constitutes an offer that is rarely refused. These
are patients whose number of physician visits a year frequently exceeds 100, with a mean of 58. Even
then, they would like to have more visits if access were easier. One patient, a research psychologist, set
what for us has been a record: 643 physician visits in one 12-month period, although we have
treated a number whose physician visits exceeded 400. This was a man in his late 40s who was
convinced he was suffering heart attacks, and negative electrocardiograms seldom reassured him
for more than a few hours or a couple of days at maximum. He would often present himself to the
emergency room (ER) before 6:00 A.M., leave reassured, only to return to the drop-in clinic by 11:00
that same morning. This rushing to the doctor was often repeated again in the afternoon or
evening. On his “bad days,” as he called them, six or more physician visits was standard behavior.
He was on the research staff of his health plan and knew personally all the cardiologists and ER
physicians, who accorded him unwarranted courtesy and deference. He was aware of the goals and
purpose of our somatization program, but he nonetheless eagerly signed on and typically never
missed a session.
The Somatization Treatment Protocol

Following the individual preparatory sessions, the somatizers enter a group program of 8 to 12
patients, depending on the traffic flow. A total of 20 group sessions are spaced over a 6-month
period as follows: 4 semiweekly sessions, followed by 14 weekly sessions, and culminating with
2 monthly sessions. Each group session is 2 hours in length. The patient has recourse to three indi-
vidual sessions that may be used at any time during the 6 months as needed, or not used at all. This
number has been found sufficient to provide access in an emotional crisis or when the patient’s
progress seems stymied and in need of individual attention, but without fostering the patient’s
ingrained desire for more and more visits.
The somatization protocol embodies all of the features present in all of the 68 Biodyne group
programs, and these elements have been extensively described (see Cummings & Cummings, 1997,
pp. 336–345). An important feature is that mixing and matching of these elements is readily accom-
plished as might be appropriate to the condition being treated, and only the unique features of the
somatization protocol will be delineated here. It should be stated that many interventions make use
of a broad range of cognitive behavior therapies (CBTs), but these are tailored to fit the somatizer.
This accommodation is the result of many years of field testing in actual delivery systems, so that
the limitations of CBT are alleviated. One of these limitations is that CBT does not pay enough
attention to basic characteristics, other than the problem presented, which define the differences
among the persons presenting. For example, a somatizer who is also a borderline personality disor-
der must be addressed differently from those who are chronically depressed, obsessive-compulsively
disordered, or addicted to prescription drugs.
Requirements. Patients are expected to attend every group session and to complete their home-
work. Failure to complete the homework results in the patient’s being sent home and forfeiting that
session. When symptoms tempt the patient to seek a medical appointment, or to rush to a nonap-
pointment visit with a physician (defined as including all physician extenders such as a physician
assistant, nurse practitioner, etc.), the patient is required to first call the “buddy” assigned to him or
her as described below.
Buddy System. Patients are randomly paired off as buddies. They are encouraged to phone each
other whenever they have a need to talk, but they are not permitted to call the psychotherapist. If a
patient breaks this rule and does call the therapist, it counts as one of the three individual visits per-
mitted during the 6 months. Patients are required to call each other before seeking a visit with
a physician, and they are further required to obtain the buddy’s agreement before seeing
the physician.
Tokens. Each patient at the first group session is given 10 coupons, each good for a visit with a
physician anytime during the 6-month treatment period. The patient is free to spend these on
physician visits with or without the agreement of the buddy, but once all 10 coupons are spent,
there are no more. If the patient is found on examination by the physician to have at that moment a
physical disease necessitating medical attention, neither the patient nor the buddy forfeits one of
their respective 10 coupons. If there is no such condition, the patient forfeits one coupon, and if the
buddy had agreed to the visit, the buddy also forfeits a coupon. If the buddy did not agree with
seeking the visit and did her or his best to dissuade the patient, the buddy does not forfeit a coupon.
This is designed to aid both patient and buddy to begin learning to differentiate between real sick-
ness and somatization, something the general population does routinely when deciding whether
they are sick enough to go to the doctor. The therapist may need reassurance here, and must be
reminded that these patients have been medically explored beyond all reason, and have been found
to have no medical disease, and certainly no life-threatening disease. In several decades of using this
protocol, there has never been an untoward medical event in which a patient who really needed the
doctor chose not to seek one. The invariable decision is in the opposite direction of seeing a physi-
cian when it was not necessary.
Psychoeducation. Information on how the body translates stress into physical symptoms is impor-
tant, but it is even more important to include simple psychodynamics tailored and woven into each
individual patient’s personal verbalizations, exquisitely timed and expertly interpreted, to help the
patient see how this goes on within his or her own life. In presenting the psychoeducational por-
tion, however, a patient who insists “I am not somatizing” is never challenged directly. The thera-
pist will get a rapid assist from the other group members who will challenge the patient. For these
patients parental attention came essentially only when the child was ill, and very likely the excuse
worked: “Mommy, my tummy hurts too much to go to school today even if I do have a spelling
test.” There are many examples of a learned response to stress that results in somatization, a pattern
that follows the patient throughout life.
Homework. There is homework, tailored to what should be the next progressive step for the
patient, given at the end of each session. This may include readings, charting the events and feelings
that precede the urge to see a physician, putting into practice “antidotes” to running to the doctor,
and later in the sequence of treatment finding long-term alternatives to seeking medical attention at
times of stress. Toward this end, relaxation and guided imagery exercises are assigned as homework.
As mentioned earlier, the homework is enforced, and the patient who has not done the homework
forfeits the session. The therapist must be prepared for the patient’s outcry, “I need therapy more
than ever this week and you are sending me home,” by replying, “Then do your homework so you
can get help from both yourself and the group.” More than anything else, the homework drives
home the concept that the patient, not the physician, is ultimately responsible for his or her own
health, and that the patient must partner with the physician toward wellness.
Veterans. At the end of the 6 months, one or two patients who have done well may express a desire
for more therapy, and they are allowed to enter a new group with an entirely new cast of patients.
The presence of one of these “veterans” in a group is a great aid to the therapist. Patients listen
when one of these veterans states, “I remember when I felt like you do, and here is what I did about it.”
Self-efficacy and learned helplessness, as described respectively by Bandura (1991) and Seligman
(1975, 1994), are of particular importance to these patients. They need the self-efficacy that comes
from accomplishing specific, and often small, tasks toward their own well-being, and they have to
overcome their learned helplessness, feeling there is nothing they can do in the face of scary physical
symptoms other than run to the doctor.
All the elements listed by Cummings and Cummings (1997, pp. 336–345) are woven into the
protocol, but special mention must be made of physical exercise because patients resist this impor-
tant antidote to anxiety and depression, and therapists, perhaps because of their own more or less
sedentary lifestyles, do not enforce it by making it part of the homework. Throughout the 6 months
the psychologist must be skilled in group dynamics, interpreting and interceding as necessary, but
allowing the group to drive home to each member the processes in their own somatization. Patients
accept a degree of directness and even bluntness from peers that they would dismiss if proffered
even tactfully by the therapist.
The Extreme Protocol

There are somatizers deemed so recalcitrant that some health plans have resorted to an extreme
procedure that has been termed a “lock-in.” The patient is assigned a PCP and the patient cannot
see any other physician or go to a specialist unless this lock-in physician approves it. This PCP is
usually highly trained in somatization, but unfortunately there often ensues a standoff between
patient and lock-in physician. In the method described in this chapter, there has never been an
experience where resorting to such a desperate measure was even considered. We have been con-
fronted with two situations, however, when our triaging of the somatizer came after the health plan
had instated a lock-in system. In both instances we worked with the lock-in physicians and adapted
our protocol to accommodate this extreme measure. It is not surprising that the patients came to
the group program hostile and resentful. There was also resistance from the lock-in physicians to
the 10-coupon freebies, inasmuch as under our system the patient was free to spend these coupons
after consulting with the buddy, but had to accept the fact that once these were spent, there would
be no more coupons until the end of the 6 months of treatment. The lock-in PCPs saw themselves
as the gatekeeper, not the coupons, and complained they would be subordinated by both a piece of
paper (the coupon) and the patient’s buddy.
An accommodation was reached in which the patient was given 15 coupons, but could redeem
them only with the lock-in physician. The increased number of coupons was to give the lock-in
PCPs the added discretion they wanted, rather than granting the patients more leeway. In both
instances where a lock-in system was in place before our arrival, it was abandoned within the first
year after this protocol had been instituted. Both the health plan, which was ever mindful of patient
complaints and even potential lawsuits, and the lock-in physicians, who had tired of being the bad
guys, heaved a noticeable sigh of relief.
Results
This method has been employed on a large scale by a number of settings for several decades with
uniformly positive results. The NIMH early on was so impressed that it funded 20 replications that
it reported in summary (Jones & Vischi, 1979). A year later it sponsored the Bethesda Consensus
Conference where all the experts in medical cost offset addressed over 3 days the wide ranging cost
savings within the uniformly positive findings. This conference concluded that the more closely the
treatment replicated our Group Method 2, the greater was the reduction in somatization (Jones &
Vischi, 1980).
The Kaiser Permanente Studies

It was at Kaiser Permanente that the term somaticizer was coined in the early 1960s and the method
of triaging them into a behavioral care system was developed (Cummings & VandenBos, 1981).
The typical reduction in somatization is illustrated in Figure 8.1, demonstrating a steady reduction
in somatization in a 5-year period, which resulted in a somatization rate for the experimental group
to a baseline that resembles the usual utilization rate of healthy, nonsomaticizing patients. The dif-
ficulty with a long line of such researches is that they were retrospective studies with a comparison,
rather than a control group. Nonetheless, these early studies were important in piquing the interest
of both researchers and program planners who were interested in health-care delivery models.
The Hawaii-HCFA-Medicaid Project

The HCFA funded in 1981 a 7-year project in Honolulu involving 36,000 Medicaid recipients and
90,000 federal employees, in which a new delivery system was created for the first time as a behav-
ioral care carve-out that interfaced with a traditional medical system under the sponsorship of the
Hawaii Medical Services Association (HMSA), the Blue Cross/Blue Shield affiliate in Hawaii.
100
90
80
Average Medical Utilization Rates
70
60
50
40
30
20
10
0
1B 1A 2A 3A 4A 5A
Years
Fig. 8.1 Average medical utilization for the year before (1B) and the 5 years after (1A, 2A, 3A, 4A, and 5A)
behavioral intervention was instituted (from Follette & Cummings, 1967).
The Hawaii project had the advantage of being a large-scale (126,000 eligible patients) prospective
study with a randomized design. As with the Kaiser Permanente experience, psychologists were
trained in the model of addressing somatization with targeted programs and without challenging
the somatization directly.
The prospective, randomized Hawaii project confirmed the results derived from years of retro-
spective studies and added a number of dimensions. First, it demonstrated that the Somatizer
Program Method 2 was instrumental in significantly reducing medical utilization in the experimental
group (the Biodyne model), while the traditional private practice, fee-for-service sector (control
group) significantly raised medical utilization, in most instances by as much as 30%. Second, the
reduction in medical utilization by those patients suffering from six chronic medical conditions
(asthma, diabetes, emphysema, hypertension, ischemic heart disease, and rheumatoid arthritis) was
even more dramatic than that of the simple somaticizers inasmuch as the protocol dramatically
increased compliance and reduced the emotional component that accompanies chronic physical
disease. The control group (treated by the private practice, fee-for-service sector) demonstrated
equally greater increases in the opposite direction: an increase in overutilization (Cummings,
Dorken, Pallak, & Henke, 1991, 1993). These findings are illustrated in Figures 8.2 and 8.3.
The Fort Bragg Study

An initially highly touted experiment with a government CHAMPUS population in North Carolina
purported that it was unlimited access to privately practicing, fee-for-service psychologists, not the
$700
$600
$500
$400
$300
$200
$100
$0
Targeted, Focused Other Mental No Mental

Therapy Health Treatment Health Treatment
Fig. 8.2 Chronically ill group. Average medical utilization in constant dollars by the Hawaii project chroni-
cally ill group for the year before treatment (lightly shaded columns) and the year after treatment (darkly
shaded columns) for those receiving targeted and focused treatment in the private practice community, and
no mental health treatment (from Cummings, Dorken, Pallak, & Henke, 1993).
$2,500
$2,000
$1,500
$1,000
$500
$0

Focused Therapy Health Treatment Health Treatment
Fig. 8.3 Nonchronic group. Average medical utilization in constant dollars for the Hawaii Project Nonchronic
Group for the year before treatment (lightly shaded columns) and the year after treatment (darkly shaded
columns) for those receiving targeted and focused treatment, other mental health treatment in the private
practice community, and no mental health treatment (from Cummings, Dorken, Pallak, & Henke, 1993).
targeted programs, that would reduce medical/surgical utilization. Congress funded $8 million to
provide unlimited psychotherapy for the study and found to its dismay that (1) it cost $80 million
and (2) it did not decrease medical/surgical utilization below that of the conventional managed care
system, which did not use targeted group programs (Bickman, 1996). In other words, a study that
cost 10 times that of the Hawaii project ($80 million versus $8.2 million) confirmed that targeted
programs, not unlimited traditional individual psychotherapy, are crucial in deriving results. The
American Psychological Association “embalmed” the findings in a special issue of the American
Psychologist and has not referred to the study since (Bickman, 1996).
Discussion
Medical Confidentiality
The health-care system changes slowly and in its reluctance to move forward it is likely to raise
issues that are tangential or irrelevant. One such issue is the matter of medical confidentiality and
whether it is compromised or even violated in the computerized identification of the 15% highest
utilizers of health care by number of physician visits. The answer is no because no information
other than utilization data are conveyed, a practice common within health systems. Whether used
for third-party reimbursement or, as in our case, for outreach, nothing more than utilization data is
exchanged. Once outreached, the patient can participate voluntarily or refuse to do so, and until the
patient is seen and discusses her- or himself with the practitioner, no medical or psychological
information is available. No health system can operate without utilization information flowing
freely within the health system that is being used by the patient. The method and protocol described
in this chapter become integral parts of that health delivery system and are of no greater or less
consequence than a PCP referring a patient to a specialist within the same medical system. It must
be emphasized that the monthly listing of the patients manifesting the 15% highest number of
physician visits is not accompanied by any information beyond frequency and dates of visits to phy-
sicians. Once the patient elects to come in after the outreach, then the patient’s medical chart
becomes available by patient consent and participation in the treatment modality.
Wither Integration?
Shaffer (2001) identifies three levels on the ladder to full integration of behavioral health in
primary care: (1) communication, (2) collaboration, and (3) integration. In the first there is com-
munication between PCPs and behavioral providers, a procedure that would seem at minimum to
be a necessity in adequate health care, but which is surprisingly absent to a significant degree in
most health delivery systems. Amazingly, it is common for PCPs to refer a patient for psychotherapy
and receive no follow-up response other than a statement of whether the patient did or did not
make an appointment with the psychologist. The reason given is that psychological information
deserves the utmost in confidentiality, but this is an irrelevant argument. The PCP neither cares
about nor needs the kind of information that the psychotherapist guards so zealously. Rather, the
PCP needs information upon which to base medical treatment decisions, such as which medication
to prescribe, and without adequate communication between PCP and psychologist, the patient is
being short-changed.
A simple yet valuable form of communication is a 24-hour, toll-free telephone number where a
PCP can obtain quick consultation with a behavioral provider about a patient manifesting psycho-
logical problems. This important communication has been shown to prevent more costly proce-
dures or preclude treatment errors, including psychiatric hospitalization, medication miscalculations,
and suicidal activity. The facility with which communication occurs can be a progression that is
characteristic of a system, or it can be no more than a regular communication that might exist
between one or two PCPs and a nearby behavioral care provider with whom they have formed a
special relationship. When one considers how absent or primitive mere communication often is
within a system, one is struck with how far off integration is. This is such an apparent lack in health
systems that MedCo/Merck was prompted to allocate $100 million to help foster communication
within a health system (Gilmartin, 2001).
Collaboration involves the active participation of a PCP and a behavioral care provider in the
treatment of a patient. Usually the behavioral care provider is a specialist who is not part of the
PCPs’ health-care system (e.g., private practitioner, group practice, separate psychiatric clinic), or if
he or she is a part of the same system, it is still as a specialist in the department of psychiatry. There
are instances in which collaboration masquerades as integration inasmuch as the psychiatric
(psychological) specialist is on colocation, giving the aura of integration.
An integrated program not only has the behavioral care provider on colocation, but the psychol-
ogist is not involved in specialty care. Rather, the psychologist is a member of the primary care team
and is no longer affiliated with specialty care, defined as a department of psychiatry or psychology
doing psychotherapy. Integration is a seamless primary care system employing a wide range of
disease and population-based programs, and may on occasion refer perhaps as many as 10% of the
patients to specialty psychiatric care as needed.
Program Matters
The somatizer cannot be addressed in a traditional system offering the usual fare of psychotherapy.
The two studies previously cited make this crystal clear. The Hawaii project, with its targeted
outreach and treatment, not only reduced somatization, but through the attendant medical cost
savings, the government recouped within 18 months the expenditure that created a new delivery
system (Cummings et al., 1991, 1993). In the Fort Bragg study, where it was thought unlimited
access would do better than targeted programs, the expected reduction in somatization did not
occur, the government recovered nothing, and Congress experienced a devastating tenfold overrun
(Bickman, 1996).
The method for the identification and treatment of the somatizer as described in this chapter
falls considerably short of being an integrated program. But it is important that it is the only single-
thrust targeted program that will yield substantial results where other single-targeted protocols
(e.g., depression pathways) fall far short of making an impact in an otherwise traditional delivery
system. Even more important, it is applicable in a carve-out relationship, which is the main form of
behavioral care delivery today, and where no significant form of integration is possible. In imple-
menting the program, however, it is important to avoid the cumbersome middle step of the physi-
cian who receives the computer printout and makes the actual referral. The results of this procedure
are disappointing, even when physicians sincerely believe they are cooperating fully. The computer
elicitation, followed by a direct and immediate outreach, will reap several times more somaticizers
in treatment than the physician-intermediary model. Furthermore, this direct outreach program is
the most adaptable to an existing carve-out system.
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Shaffer, I. A. (2001). Managed care: Cost and effectiveness. In N. A. Cummings, W. O’Donohue, S. C. Hayes, & V. Follette,
Integrated behavioral healthcare: Positioning mental health practice with medical/surgical practice (pp. 187–206). San
Diego, CA: Academic Press.
Strosahl, K. (1997). Building primary care behavioral health systems that work: A compass and a horizon. In N. A. Cummings,
J. L. Cummings, & J. N. Johnson (Eds.), Behavioral health in primary care: A guide for clinical integration (pp. 37–58).
Madison, CT: Psychosocial Press/International Universities Press.
Strosahl, K., Baker, N. J., Braddick, M., Stuart, M. E., & Handley, M. R. (1997). Integration of behavioral health and primary
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Behavioral health in primary care: A guide for clinical integration (pp. 61–86). Madison, CT: Psychosocial Press/
International Universities Press.
Chapter 9
Treating Attention Deficit Hyperactivity
Disorder and Oppositional Defiant
Disorder in the Primary Care Setting
WILLIAM E. PELHAM, JR., DAVID MEICHENBAUM, AND GREGORY A. FABIANO
Children with attention deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder
(ODD) are typically treated within the primary care setting, though there is often a discord between
the current evidence-based treatment recommendations for these disorders and current practice.
Effective interventions will include a standard assessment using validated rating scales, psychosocial
treatment components including school-based behavioral and academic interventions, parenting
programs, and child-focused programs that improve peer relationships and academic achievement.
After psychosocial programs are established, a stimulant medication trial may be initiated and
adjunctive medication used, if necessary. Treatment approaches will need to be chronic and com-
prehensive to be effective for most children with ADHD/ODD.
Externalizing behavior disorders, also known as disruptive behavior disorders (DBDs), are the
most commonly occurring childhood mental health problem faced by mental health professionals,
educators, and primary care physicians (Lahey, Miller, Gordon, & Riley, 1999; Rushton, Bruckman,
& Kelleher, 2002). Of these disorders, ADHD, affecting 3–7% of the school-age population (American
Academy of Pediatrics, 2000; American Psychiatric Association, 1994), attracts the most attention
in popular media. ADHD is characterized by difficulties in core symptoms of inattention, hyperac-
tivity, and impulsivity. The other DBDs—ODD and conduct disorder (CD)—are also common
childhood problems seen in primary care settings with rates of diagnosis as high as ADHD (American
Psychiatric Association, 1994; Lahey et al., 1999). ODD is characterized by oppositional and defiant
behavior directed at adults. Children with CD exhibit serious antisocial behavior, including aggres-
sion, stealing, lying, and property destruction. It is useful to think of ODD and CD as a continuum,
with CD being the more extreme variant of antisocial behavior and emerging in childhood later
than ODD.
These disorders are highly co-morbid. In preschool children it is difficult to discriminate among
them (e.g., Campbell, Szumowski, Ewing, Gluck, & Breaux, 1982). In school-age epidemiological
samples, up to 50% of children with ADHD have co-morbid ODD and 15% have co-morbid CD,
with widely varying rates across studies (see Lahey et al., 1999, for a review). In clinical populations,
177
co-morbidity between ADHD and ODD/CD is even higher, with 75% of clinical study ADHD
samples having co-morbid ODD and 25% CD (e.g., Pelham, Waschbusch et al., 2001; Pelham,
Hoza et al., 2002). Comorbidity of ADHD in clinic samples selected for ODD and CD are similarly
high (Schuhman, Foote, Eyberg, Boggs, & Algina, 1998). Further, there is a developmental sequence
for the relationship among these disorders, with ADHD beginning earliest, a proportion of
ADHD children later developing ODD, and a proportion of those individuals later developing
CD (Chamberlain & Patterson, 1995). Further, a proportion of the CD individuals continue into
adolescence to develop delinquent behaviors.
Children with externalizing disorders experience serious social, emotional, and academic prob-
lems across the multiple settings of school, home, and peer network. It has become well established
that impairments in functioning associated with childhood DBDs persist throughout one’s life.
Risk for negative outcomes in adolescents and adults with ADHD, ODD, and CD include school
and vocational failure, dysfunctional interpersonal relationships, criminal behavior, and alcohol or
other substance abuse (Frick & Loney, 1999; Mannuzza & Klein, 1999). If a child has concurrent
ADHD and ODD/CD, the risks of such negative outcomes increase dramatically relative to the single
disorders (Lynam, 1996). The costs to the individual and society of the adult outcomes of children
with DBDs are enormous. Thus, the development and implementation of effective childhood
interventions is critical both to offset the costs to our society associated with childhood DBDs and to
prevent the development and expense of ever more serious outcomes in adolescence and adulthood.
The etiology of ADHD and ODD/CD is still unknown; however, many view ADHD as being a
biopsychosocial phenomenon. First, while no biological markers have been reliably identified in
probands, there is a greater rate of concordance among biological relatives (Epstein et al., 2000)
and in twin studies, and molecular genetic studies provide strong evidence for a genetic role in
ADHD (Castellanos, 1999; Castellanos et al., 2002). At the same time, environmental and familial
stressors have also been linked to elevated risk for and exacerbation of ADHD symptoms. A recip-
rocal relationship has been established between ADHD in children and parental psychopathology
(e.g., depression), dysfunctional marital relations, parental use of alcohol or substances, and
elevated parent-child conflict (Mash & Johnston, 1990; Pelham & Lang, 1999). Finally (as will be
noted below), the symptoms and impairment associated with ADHD are effectively treated in the
short term by either pharmacological or behavioral treatments. Thus, with respect to etiology and
mechanism, as well as intervention, ADHD is a biopsychosocial phenomenon.
In contrast, it is generally thought that aggressive disorders, such as ODD and CD, are more
affected by environmental circumstances such as poverty and poor parenting than by biological
influences (McGee & Williams, 1999). Robin (1998) goes so far as to describe ODD as being “an
interactional problem of a family system, not a disorder that resides inside a child/adolescent”
(p. 62). At the same time, biological factors have been argued to play a role in ODD and CD,
though the evidence is not as strong as for ADHD (Pliszka, 1999; Sanson & Prior, 1999). ODD and
CD are treated primarily and effectively with psychosocial treatments. Although there has long
been interest in discovering a medication to treat aggressive behavior in children, there is no FDA-
approved medication for ODD or CD. At the same time, it is important to emphasize that for a
given child, the co-morbidities among ADHD, ODD, and CD are so high that a child in primary
care is more likely than not to have both ADHD and ODD or CD. In such cases, medication for
ADHD is as effective as for ADHD children without co-morbid ODD/CD, and ODD/CD–related
symptoms are diminished.
Thus, ADHD and ODD/CD are thought to have, at least in part, biological bases. At the same
time, it is clear that psychosocial factors influence the development of the disorders and offer the
most studied evidence-based treatment.
Treating ADHD and ODD in the Primary Care Setting • 179
Evidence-Based Treatments for ADHD and ODD/CD

ADHD and ODD/CD have been treated in a variety of settings in a broad variety of ways, including
traditional one-to-one therapy, cognitive therapy, play therapy, restrictive or supplemental diets,
biofeedback, treatment for inner ear problems, allergy treatments, chiropractics, pet therapy, and
sensory integration training, among others. None of these interventions, however, have been dem-
onstrated to be effective in treating ADHD and ODD/CD. Only three treatments have been
validated as being effective, short-term treatments for these disorders: (1) central nervous system
(CNS) stimulant medication (for any child with ADHD), (2) behavior modification (i.e., parent
training, classroom interventions, peer interventions; for any child with either ADHD or ODD/CD),
and (3) the combination of stimulant medication and behavior modification (for any child with
ADHD). The large research base demonstrating the effectiveness of these three treatments
(e.g., Barkley, 1998; McMahon & Wells, 1998) has led to the endorsement of these interventions by
the Society for Clinical Child and Adolescent Psychology (Brestan & Eyberg, 1998; Pelham,
Wheeler, & Chronis, 1998), the National Institutes of Health (NIH; NIH, 2000), the American
Medical Association (AMA; Goldman, Genel, Bezman, & Slanetz, 1998), the American Academy of
Pediatrics (AAP; AAP, 2001), and the American Academy of Child and Adolescent Psychiatry
(AACAP; AACAP, 1997a, 1997b). It is notable that the AAP and AMA guidelines apply only to
ADHD; ODD and CD have not been addressed by these groups.
As noted above, there is high diagnostic overlap among ADHD, ODD, and CD. Fortunately, this
overlap does not create difficulties in deciding which treatments to utilize. Effective psychosocial
treatments for ADHD and ODD/CD are identical, and response to treatment does not vary as a
function of co-morbidity (Conduct Problems Prevention Research Group, 1999; Kolko, Bukstein, &
Barron, 1999; MTA Cooperative Group, 1999b; Pelham et al., 1993). Children with co-morbid
disorders may be more severely impaired and require more intensive or comprehensive behavioral
treatments, including stimulant medication; however, the co-morbidity does not mean that alter-
native treatments are needed beyond those indicated.
Despite a large evidence base documenting the effective treatments for ADHD and ODD/CD,
and published guidelines endorsing the use of these treatments, a review of current practice in
primary care settings reflects a discord between what is recommended and what is implemented.
Before we turn our attention to evidence-based assessment and treatment in primary care settings,
we first address the occurrence and typical treatment of ADHD and ODD/CD in these settings.
ADHD and ODD/CD in the Primary Care Setting

Although ADHD and ODD/CD are mental health disorders, it is often primary care physicians
who are responsible for diagnosing, treating, or referring the child (Costello, 1986; Kwasman,
Tinsley, & Lepper, 1995; Rushton et al., 2002). ADHD and related disruptive behavior disorders
have become a prevalent and escalating problem within primary care settings. Data from the Child
Behavior Study (CBS), a data set compiled from two large international practice-based primary
care networks consisting of more than 2,000 clinicians from more than 600 practices, indicate that
19% of children have a psychosocial problem on presentation at the physician’s office—half for
ADHD, and 37% for “behavioral or conduct problems”—that is, ODD or CD (Rushton et al.,
2002). Similarly, data from the National Ambulatory Medical Care Survey (NAMCS) indicates that
about 60% of all children’s visits to physicians, where a mental health problem was identified as the
primary reason for the visit, were a result of the child’s having ADHD (Hoagwood, Kelleher, Feil, &
Comer, 2000). Moreover, there was a threefold increase between 1989 and 1996 in the number of
office-based visits resulting in a diagnosis of ADHD. It is interesting to note that diagnostic
differences in ADHD were not found across racial, economic, and familial status, highlighting the
pervasiveness of the disorder across demographic groups (Wasserman et al., 1999). Despite the
increase in diagnosis rates, there is evidence that ADHD, and childhood psychopathology in
general, is underdiagnosed and untreated within the community and pediatric primary care
(Angold, Costello, Farmer, Burns, Erkanli, 1999; Costello, 1989).
A common practice among primary care physicians is to make referrals to other professionals
(e.g., child psychiatrists, psychologists, counselors, social workers) to develop and implement treat-
ments. Moser and Kallail (1995) conducted a survey indicating that 43% of family physicians
referred children they suspected to have ADHD to other professionals in the community. Making
referrals to other professionals, however, may not always be a viable or preferred option. The CBS
study discussed above found that only 17% of the identified ADHD cases were referred for other
interventions, with half of these referrals to psychologists. Further, fewer than half of referred
patients actually followed through with contact with a mental health specialist (Rushton et al.,
2002). The CBS participants cited the availability of an expert as the primary stumbling block to
referrals. In place of referring out for services, the primary care providers reported their two
most common “treatment” strategies were watchful waiting (38%) and nonspecific counseling
(33%)—both contraindicated for treating externalizing behavior disorders. For children with
ADHD, nonspecific, in-practice counseling was often combined with medication. However, for
behavior or conduct problems, no medication was being used. Clearly, this raises the question of
the quality of treatment for ADHD and ODD/CD that is being delivered in these settings.
In summary, given the prevalence of ADHD and ODD/CD in primary care settings, along with
the impairing nature, chronicity, and cost associated with the disruptive disorders, it is imperative
to explore ways to implement effective evidence-based treatments for ADHD and ODD/CD within
primary care settings.
Pharmacological Treatment Practices for ADHD

The most widely used and studied treatment for ADHD is stimulant medication (Spencer et al.,
1996; Swanson, McBurnett, Christian, & Wigal, 1995). Stimulants are clearly effective in suppress-
ing the symptoms of ADHD in the short term. With one recent exception (Biederman, Heiligenstein,
et al., 2002) stimulant medications are the only pharmacological agents with strong empirical
support for effectively treating ADHD. Other psychotropic medications are not validated for use in
children with ADHD, even though many physicians prescribe these medications off label (Guevara,
Lozano, Wickizer, Mell, & Gephart, 2002; Jensen et al., 1999). Given that the efficacy and side effect
profiles of nonstimulant drugs are not sufficiently documented, either alone or in combination
with stimulants, we will only discuss the use of stimulants.
Stimulants are relatively inexpensive, are easy to administer, and result in significant acute
improvements in key domains of functioning for approximately 70% of children with ADHD
(Swanson et al., 1995). Typical beneficial effects of stimulant medication include increased
academic task completion, decreased disruption and aggression, and increased compliance with
adult directions. As a result, administering stimulant medication to children with ADHD is the
overwhelming treatment practice adopted by primary care physicians. Data from the NAMCS
indicate an increase in stimulant prescriptions from 54.8% of primary care visits in 1989 to 75.4%
in 1996 (Hoagwood et al., 2000), and stimulant prescription has continued to increase dramatically
in the 8 years since (Zito et al., 2003).
Despite the widespread use of CNS stimulants and the fact that they are an evidence-based
treatment for ADHD, one must be cognizant of their limitations as a sole intervention. First,
the effects of medication are not uniform. That is, approximately one third of all children show
either no response or an adverse response to medication (Pelham & Smith, 2000). Second, like all
medications, stimulants have side effects—primarily insomnia and appetite suppression, but they
may also result in other problems such as headaches, stomachaches, anxiety, and irritability, and
they may exacerbate motor tics (Kurlan et al., 2002). At times these side effects may preclude the use
of a high dose of medication or give physicians and families cause to discontinue medication alto-
gether. For example, although evidence from early studies suggested that growth suppression was
not a problem with stimulant therapy, more recent evidence suggests that stimulant therapy lasting
2–3 years may result in permanent effects on growth (Kramer, Loney, Ponto, Roberts, & Grossman,
2000; MTA Cooperative Group, 2004). Third, despite the short-term benefits of stimulants, there is
no evidence that documents the long-term efficacy of stimulants in improving areas of impairment
and outcome (Swanson et al., 1995). Fourth, even with the increase in longer acting medications,
the effects of the medication are only evident 30–60 minutes after administration and the effects are
only present while the medication is active. Given that the side effect of insomnia precludes use of
stimulants for many children during the evening hours, parents are often left to deal with their child
in the morning and evenings when they are unmedicated. Fifth, medication alone is often not suffi-
cient in bringing the child back to a normal range of functioning (Swanson et al., 2001), likely
because important functional domains, such as academic and social skills, parent-child interac-
tions, teacher- and parent-child management skills, reduced self-esteem, and co-morbid problems
such as oppositional and conduct behavior, specific learning disabilities, anxiety, and depression are
not directly addressed with stimulant medication treatment. Furthermore, administering medica-
tion may reduce the motivation and likelihood that parents and teachers will initiate and employ
psychosocial treatments that may address the remaining impaired areas of functioning.
Perhaps the most important limitation of stimulant medication as a treatment for ADHD is the
lack of parent satisfaction with the treatment. There is a general dissatisfaction among parents and
teachers for the use of pharmacological treatments with children, and a very strong preference for
behavioral treatments (Liu, Robin, Brenner, & Eastman, 1991). For example, in the multimodal
treatment study for ADHD (MTA), parents were 15 times more likely to drop out of or be dissatis-
fied with the medication group compared with the behavior therapy group, and only half as likely
(34% versus 64%) to be strongly satisfied with the treatment (Pelham, Gnagy, Greiner, & MTA
Cooperative Group, in press). Given the chronicity of the disorder, it is critical that treatments for
ADHD and ODD/CD be sufficiently palatable to families that they will be continued in the long
run; it does not appear that medication employed as the sole intervention is a palatable treatment
for families.
Finally, negative attitudes of children and adolescents about medication may result in poor
compliance with medication regimens (Sleator, Ullmann, & von Neumann, 1982). A number of
studies have shown that ADHD children do not believe that their medication has a beneficial
effect on their functioning (Pelham, Hoza, Kipp, Gnagy, & Trane, 1997; Pelham, Hoza et al. 2002;
Pelham, Waschbusch et al., 2001). This fact may mean that ADHD children, with or without ODD/CD,
will not continue taking medication when they reach the age at which they have a voice in their
treatment. Recently we have examined the long-term medication practices of children as they have
moved into adolescence and young adulthood and found that 49% of children who were ever
medicated stopped using medication between the ages of 11 and 15 (Meichenbaum, Gnagy,
Flammer, Molina, & Pelham, 2001). This is troubling given that preadolescence and early adoles-
cence are critical transitional periods where developmental, social, and academic demands warrant
the continued use of medication, and medication is acutely effective at these ages (Evans et al.,
2001; Smith et al., 1998).
In recent years a new generation of stimulants that can be taken once a day and have effects into
the evening has been developed to deal with some of these limitations (e.g., Biederman, Lopez,
Boellner, & Chandler, 2002; Pelham, Gnagy et al., 2001). They have shown improved coverage
during school (without midday doses) and into the evening hours, and they are effective in that
role. At the same time, this advantage comes at a cost. The typical ADHD child who was previously
medicated with 15 or 20 mg methylphenidate per day must take, for example, 36 mg of Concerta to
have the same effect—an 80–140% increase in total daily dose. Since total daily dose predicts
growth retardation (Kramer et al., 2000), this is a decided limitation of the new agents.
In summary, stimulant medication is a useful treatment for the majority of ADHD children. At
the same time, its limitations mean that treatment plans for children with ADHD, with or without
ODD/CD, must be more comprehensive in scope than medication alone (AAP, 2001). Since there is
no effective medication for ODD or CD, it is clear that psychosocial treatments form the basis of
treatment for them. Because these practice parameters include behavior modification treatment as
an important component of treatment, practitioners of behavior modification are integral contrib-
utors to treatment in the primary care setting.
Diagnosing and Assessing ADHD and ODD/CD in Primary Care

The American Academy of Pediatrics (2000) notes that the initial evaluation for an ADHD patient
will often take two to three visits. In practice, however, the majority of pediatricians spend 50 to 60
minutes on an initial ADHD consultation, whereas family practitioners spend on average between
23 and 29 minutes (Kwasman et al., 1995; Wolraich et al., 1990). Given the financial pressure in
primary care, the typical pediatric office visit lasts 10 minutes. Thus, it is not surprising that
the major problem identified by pediatricians in having children with ADHD in their practice is the
amount of time required to work with them.
Since time is a major barrier in both primary care and mental health settings, it is critical that
the assessment techniques being employed are both effective and efficient. At this point the assess-
ment of ADHD and ODD in primary care settings lacks standardization (Wasserman et al., 1999).
There is no medical, neurological, or psychological test that provides a valid diagnosis of ADHD or
ODD/CD (AACAP, 1997a and 1997b; AAP, 2000). ADHD and ODD/CD are instead defined by a
group of behavioral symptoms. Although these are observable characteristics (e.g., short attention
span, defiance), it has been well established and well communicated that ADHD and ODD cannot
be validly diagnosed by observing a child during an office visit. In addition, ADHD children and
ODD children are not veridical reporters of their own functioning (Hoza, Pelham, Dobbs, &
Owens, 2002), so interviewing them regarding their symptoms and impairment is not useful in
diagnosis. Rather, diagnosis must evaluate the child’s behavioral symptoms and associated impairment
in the settings of interest—the home and school.
Over the past several decades, many researchers and clinicians have emphasized the importance
of making an accurate diagnosis for ADHD and ODD using symptoms identified in the Diagnostic
Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994). Some
primary care physicians may be using the DSM-PC, an AAP modification of the DSM (American
Academy of Pediatrics, 1996). Criteria for diagnosis of a disorder are identical in the two manuals;
the DSM-PC introduces a subdiagnostic level of problematic behavior that has face-validity but has
not been the focus of research.
Although the DSM system has improved the reliability of diagnosis and is useful in screening for
ADHD and ODD, its utility is limited because the presence of DSM symptoms alone does not
provide any useful information about treatment (Scotti, Morris, McNeil, & Hawkins, 1996). In
addition to symptom presence, impairment is required to diagnose both ADHD and ODD in the
DSM. For ADHD, impairment is required in home, school, or peer functioning in at least two
settings. It is these impairments in daily life functioning (e.g., a child is failing a class because he or
she fails to hand in completed homework assignments a family cannot take a child out in public
because of embarrassing temper tantrums) that are far more important in the assessment process
than are DSM symptoms. This is true for several reasons. First, problems in daily functioning
become the natural targets of treatment, and improvement in these areas is the natural index of
treatment outcome (Pelham & Fabiano, 2000). Second, the importance of impairment is under-
scored by the finding that the use of clinical services is precipitated by impairment, not symptoms
(Angold et al., 1999). Children are not referred to physicians or psychologists because of DSM
symptoms; instead they are referred because of their problems in daily activities at school, with
peers, or at home. Finally, the most important predictor of negative long-term outcomes for the
disruptive behavior disorders is the initial severity of behavioral impairment, not diagnosis (Pierce,
Ewing, & Campbell, 1999). The three domains most predictive of long-term outcomes for children
with disruptive behavior (including ADHD and ODD) are academic achievement and school func-
tioning, parent-child relationships and parenting skills, and peer relationships (Chamberlain &
Patterson, 1995; Coie & Dodge, 1998; Hinshaw, 1992). Indeed, functioning in these domains
mediates outcome, and improvement in the impaired domains must be achieved to avoid continued
problems throughout development.
Table 9.1 presents a set of guidelines to facilitate and foster the timely, thorough, and valid
assessment of ADHD and ODD/CD children in primary care. The guide incorporates a behavioral
approach to assessment (Mash & Terdal, 1997), the AAP guidelines for ADHD (AAP, 2000), and a
well-validated approach for assessing ODD/CD (McMahon & Wells, 1998). The table also includes,
when possible, the sites on the World Wide Web from which useful assessment instruments can be
downloaded at no cost.
Given the discussion above, it should be clear that the focus of assessment should be on problems
in daily life functioning and adaptive skill deficits rather than on DSM symptoms. The assessment
typically takes more than one session. In part, establishing this phase of treatment as requiring
more than the initial contact serves as a control for the physician’s tendency to diagnose and pre-
scribe medication in the first visit. Assessment should involve a clinical interview with the parent
regarding the child’s functioning across important domains (home, school, peer), with a detailed
listing of the target behaviors, antecedents, and consequences, and a functional analysis of the rela-
tionships among these. A comprehensive interview will facilitate the conceptualization of the case
and lay the groundwork for intervention. Because this interview will take more time than a primary
care physician will be able to spend, a collaborating mental health professional or nurse in the
doctor’s office is the best person to perform this task. A comparable interview should be conducted
with the child’s teacher either face to face, via phone, or via questionnaire.
In addition to identifying targets for treatment and developing the intervention—both activities
that focus on impairment and adaptive skills—the assessment will involve making a diagnosis.
Diagnosis must typically be given for third-party payments and administrative purposes, including
eligibility for special educational services under the “other health impaired” category of the
Individuals with Disabilities Education Act (IDEA). Although the gold standard in psychiatry is to
make diagnoses using a formal structured interview (e.g., DBD Structured Interview, wings.buffalo.
edu/adhd; K-SADS, www.wpic.pitt.edu/ksads/default.htm), such instruments are lengthy, staff-
time intensive, and therefore very costly compared to rating scales that yield the same information.
Thus, ratings from parents and teachers on standardized rating scales of DSM symptoms are more
appropriate for a primary care context (AAP, 2000).
There are two types of rating scales. The first type comprises broad-band, empirically derived
parent and teacher rating scales (e.g., Child Behavior Checklist, Achenbach, 1991; Revised Conners
Rating Scales, Conners, Sitarenios, Parker, & Epstein, 1998). These screen for many problem areas
and do not use DSM symptoms but instead empirically derived items and factors. More appropriate
for the present purposes are the rating scales specific to the disorders of ADHD and ODD/CD
TABLE 9.1 Assessment Guidelines for Practitioners Working in Primary Care for a Child With ADHD, ODD,
or CD
1. Send parents and teachers standardized rating scales assessing DSM symptoms of ADHD, ODD,
and CD to be completed and reviewed prior to intake evaluation. Use the following for diagnosis:
• Disruptive Behavior Disorders Rating Scale (Pelham, Gnagy, Greenslade, & Milich, 1992,
http://wings.buffalo.edu/adhd)
• Vanderbilt Rating Scale (AAP & NICHQ Toolkit, 2002,
http://www.nichq.org/resources/toolkit/)
• ADHD Rating Scale (DuPaul et al., 1998)
• SNAP rating scale (Atkins, Pelham, & Licht, 1985, http://adhd.net)
2. Send parents and teachers standardized scales to assess impairment in daily life functioning and
adaptive skills (e.g., Children’s Impairment Rating Scale; Fabiano et al., 1999, http://wings.buf-
falo.edu/adhd).
3. Conduct a clinical interview (e.g., CCF Intake Outline, http://wings.buffalo.edu/adhd) with par-
ents to determine areas of impairment, age of onset, duration of problem, the settings where
symptoms occur; inquire about antecedents and consequences to behavior and functions of
behavior; identify targeted behaviors for treatment; gather other information relevant to case
conceptualization.
4. Ask parents and teachers to describe parenting and disciplining strategies and their effectiveness
(e.g., Teacher Behavioral Practices Interview, http://wings.buffalo.edu/adhd).
5. If suspect co-morbid diagnoses other than disruptive behavior disorders, screen with broad-band
rating scales (e.g., Child Behavior Checklist; Achenbach, 1991).
6. Determine presence of other familial conditions that may exacerbate impairment and/or compro-
mise treatment (e.g., parental psychopathology, parental substance use, marital distress, socioeco-
nomic status, single parent).
7. Complete a physical to ensure that, if needed, there are no medical reasons to preclude the use of
stimulant medication.
8. Do not use broad-band rating scales, neuropsychological tests, attentional tasks, tests for soft or
hard neurological signs, biological laboratory tests, psychoeducational tests, or observations of
office behavior in making a diagnosis.
9. Refer for other specific evaluation if necessary (e.g., psychoeducational testing for school place-
ment/determination of eligibility for school services, speech and language evaluation).
(e.g., ADHD Rating Scale, DuPaul, Power, McGoey, Ikeda, & Anastopoulos, 1998; Disruptive Behav-
ior Disorder Rating Scale, Pelham Gnagy, Greenslade, & Milich, 1992; SNAP Rating Scale, Atkins,
Pelham, & Licht, 1985; and the Vanderbilt Rating Scale, AAP & NICHQ, 2002). These scales typically
include the DSM items for the disruptive behavior disorders (ADHD, ODD, and CD), are used with
both parents and teachers, have excellent (and comparable) psychometric properties, and are avail-
able without charge on the World Wide Web (see Table 9.1). For the purpose of diagnosis of ADHD
and ODD, only these scales are necessary. For the purposes of screening for other potential problem-
atic behaviors and domains, broad-band scales are complementary to the DSM-based scales.
Thus far, rating scales have not been routinely used as a primary component of assessment in
primary practices (Goldman et al., 1998; Moser & Kallail, 1995), and are only recommended,
not required, in the AAP diagnostic guidelines (AAP, 2000). This is surprising because rating scales
offer a quick and effective method to assess DSM symptomatology. We recommend that parents
and teachers complete all rating scales prior to their first meeting with the clinician in order to
maximize the efficiency of the diagnostic process. This can be accomplished through prior mailing
or Web-based procedures. The newly released ADHD toolkit for primary care physicians (AAP &
NICHQ, 2002; www.nichq.org/resources/toolkit/) includes a DSM-symptom–based rating scale
that assesses both ADHD and ODD items, so it is likely that use of these rating scales in primary
care will increase.
Although DSM-based standardized rating scales provide information about the presence of
symptoms, impairment must also be assessed to make a diagnosis and particularly to identify
domains for target behaviors. The ADHD toolkit includes a brief scale for assessing impairment.
Another one that has better psychometric properties, is well validated, sensitive to treatment effects,
and widely used is the Children’s Impairment Rating Scale (CIRS; Fabiano et al., 1999; see Table 9.1).
The CIRS uses a simple format to assess functioning in several key domains—relationships with
adults and peers/siblings, academic functioning, disruptive behavior, self-esteem, and overall func-
tioning—and allows parents and teachers to include a narrative about the child in each of these
domains. Scales assessing impairment are essential components of a comprehensive assessment that
will directly inform treatment planning and evaluation.
The mental health clinician should also routinely assess for other potentially coexisting condi-
tions within the child (e.g., learning disabilities, language difficulties) and family (e.g., parental
depression or substance use, marital distress), along with barriers (e.g., single-parent household,
poverty) that may be contributing to the child’s dysfunction and compromising treatment. When
identified, referrals should be made to practitioners who implement evidence-based treatments for
the appropriate disorder, and modifications to the treatment plan should be made.
The AAP guidelines for diagnosing ADHD (AAP, 2000) are useful for identifying aspects of
assessment that are not useful for children with disruptive behavior disorders. Specifically, neurop-
sychological assessments, continuous performance tests, tests of executive functioning, psychoedu-
cational evaluation, personality or projective testing, neurological examinations, EEG, and other
biological laboratory assessments (e.g., tests of thyroid function) have not been shown to be useful
in diagnosing or assessing children with disruptive behavior problems.
In summary, a comprehensive assessment is the first step in developing an effective individualized
treatment plan. By replacing inefficient and ineffective evaluation methods (e.g., interviewing
children, neuropsychological evaluations, structured interviews with parents) with efficient and
effective assessment methods, clinicians can reduce the amount of time necessary for assessment
and diagnosis, allowing for a greater portion of contact time to be spent on treatment.
Behavior Modification
Behavioral treatments have a long history of documented effectiveness as an intervention for
disruptive behavior disorders and their associated problems (e.g., poor peer relationships, conflictual
parent-child relations, aggression, and low academic achievement), and they clearly result in clini-
cally meaningful behavior change (Brestan & Eyberg, 1998; DuPaul & Eckert, 1997; Pelham,
Wheeler et al., 1998). The goals of behavioral treatments for these disorders are to minimize the
child’s impairment and maximize his or her adaptive functioning and to teach skills to parents and
teachers (Pelham & Fabiano, 2000).
Table 9.2 provides management guidelines for working with ADHD and ODD/CD in primary
care settings. Table 9.3 provides the specifics of behavioral interventions for parents, schools, and
children with these difficulties.
The first issue to consider is where behavior modification falls in the comprehensive treatment
plan for the child. For a child with only ODD or CD, this is not an issue. Since medication is used
with far more ADHD children than is behavior modification, behavior modification is typically not
the first-line treatment for children with ADHD, whether co-morbid or not. Indeed, based primarily
TABLE 9.2 Management Guidelines for Practitioners Working in Primary Care for a Child With ADHD, ODD,
or CD
Treatment Planning
1. Integrate parent and teacher reports from assessment.
2. Establish target behaviors (e.g., completes academic work on time, is not aggressive during recess),
focusing on areas of impairment (i.e., classroom behavior, academic functioning, parent-child
and parent-teacher interactions, peer relationships), from which treatment outcome will be
judged.
3. Introduce and describe to parents school-based support for ADHD, such as Section 504 behavioral
plans or classification as a special education student and the development of an IEP (ADHD
Toolkit, AAP, 2002; also available at http://www.ed.gov.index.jsp, http://www.nichq.org/resources/
toolkit/).
4. Offer or refer child for services to manage problems that cannot be dealt with in a mental health or
primary care setting (e.g., intervention for a reading disability).
5. Offer or refer family for services to manage coexisting problems (e.g., ADHD, marital conflict,
anger-management problems, paternal substance use, maternal depression).
6. Inform parents of community based support groups (e.g., CHADD; http://www. chadd.org).
Treatment
1. Treatment always begins with behavior modification (see Table 9.3) first to determine the effective-
ness of this approach alone and avoid medication if possible (“first, do no harm”), and behavioral
interventions will double as indicators of treatment response (e.g., percentage of daily report card
targets met—see Table 9.4 for a sample).
2. If behavior modification alone is insufficient to normalize functioning, determine if a double-blind,
randomized, placebo-controlled, school-based medication assessment should be combined with
the ongoing behavior modification treatment. If yes, see Table 9.5.
Maintenance, Monitoring, and Follow-Up
1. Reemphasize to parents and teachers that ADHD is a chronic disorder in need of chronic treatment
and that treatment effects will not be maintained without continued treatment. Therefore, estab-
lish a comprehensive, chronic treatment plan and evaluate and modify it on an ongoing basis.
2. Adherence to treatment components is regularly checked, and treatment goals are continually
added, deleted, or modified based on an ongoing functional analysis of behavior.
3. Schedule periodic follow-up visits to evaluate changes in functioning and emerging problems.
4. Assist in troubleshooting failed treatment strategies.
5. Offer continued support and make self available for questioning for as long as necessary.
6. Reestablish contact for major developmental transitions (e.g., school entrance at kindergarten,
adolescence).
on one recent NIMH collaborative trial, the Multimodal Treatment Study for ADHD (MTA Coop-
erative Group, 1999a), medication is being increasingly widely recommended as the first-line inter-
vention for children with ADHD (AACAP, 2002; MTA Cooperative Group, 1999a). In addition
and also based on this study, current medication guidelines recommend that dosages for ADHD
children be “pushed” to the maximally effective dose (AAP, 2001; AACAP, 2002). However, there is
good reason to avoid medication and to use low dosages of stimulants. The most salient reason
is “first, do no harm.” If we know that we can avoid medication and offer an effective treatment
alternative, then primary care practitioners should be doing that routinely—or at least informing
parents of that alternative and letting parents choose. The data on parent preference suggests
TABLE 9.3 Behavior Modification Treatment Guidelines for Practitioners Working in Primary Care for the
Management of a Child With ADHD, ODD, or CD
General Guidelines
1. Treatment always begins first with behavior modification to determine the effectiveness of this
approach alone and avoid medication if possible, and behavioral interventions will double as
measures of treatment response (e.g., percentage of daily report card targets met).
2. Behavioral approach; therapist teaches parents and teachers contingency management techniques
and other behavior management skills to use with the child and the parent, and teacher imple-
ments the treatment. An expansive list of helpful readings and resources is available in the
“ADHD psychosocial treatment information sheet for parents and teachers” located at http://
wings.buffalo.edu/adhd.
3. Focus on specific target behaviors that reflect impairment in key domains of functioning (e.g., peer
relationships, parenting skills and family relationships, academic and school functioning); mal-
adaptive behaviors are targeted for reduction and adaptive skills are targeted for development.
Parent Training
1. Educate parents about the diagnosis, causes, prognosis, and treatments of ADHD (e.g., “What Par-
ents and Teachers Should Know About ADHD/ODD/CD,” available at http://wings.buffalo.edu/
adhd; http://www.chadd.org).
2. Use standard, manualized group parent training procedures for 8–16 sessions (e.g., Barkley, 1998;
Cunningham, Bremner, & Secord-Gilbert, 1998; Forehand & Long, 1996; Robin, 1998; Sanders et
al., 2000; http://www.pfsc.uq.edu.au/02_ppp/ppp.html; Webster-Stratton, 1992, http://
www.incredi bleyears.com).
3. Focus on teaching parents appropriate positive behavior management strategies (e.g., praise, reward
programs) and effective nonphysical discipline strategies (e.g., time out).
4. Help parents establish, monitor, and modify as needed a home-based daily report card and reward
system; see “Creating a Daily Report Card for the Home” at http://wings.buffalo.edu/adhd.
5. Supplement with individual parent sessions as necessary to individualize programs to the child’s
problems, provide further instruction/coaching, or modify existing behavioral programs.
School Intervention
1. Educate teachers about the diagnosis, causes, prognosis, and treatments of ADHD (e.g., ADHD
Toolkit, AAP, 2002, http://www.nichq.org/resources/toolkit/; “What Parents and Teachers Should
Know About ADHD” available at http://wings.buffalo.edu/adhd; http://www.chadd.org).
2. Use standard, manualized teacher training procedures (e.g., Pelham, 2002; Pfiffner, 1996; Walker,
Colvin, & Ramsey 1995; Walker & Eaton-Walker, 1991; http://www.pbis.org/).
3. Focus on teaching teachers appropriate positive behavior management strategies (e.g., praise,
reward programs) and effective nonphysical discipline strategies (e.g., time out).
4. Work with the teacher to construct a daily school-home report card that lists the child’s target
behaviors (see Table 9.4; see “How To Establish a Daily Report Card” at http://wings.buffalo.edu/
adhd). The daily report card is sent home to the child’s parents each day, and the parents provide
a positive consequence at home for each goal met.
Child Intervention
1. Behavioral and developmental approach—involving direct work in natural or analogue settings—
not clinic settings.
2. Focus on specific target behaviors that reflect impairment in multiple domains of functioning (e.g.,
peer relationships, interactions with adults, sibling relationships, academic skills, classroom and
family functioning, self-esteem); maladaptive behaviors are targeted for reduction and adaptive
skills (e.g., social skills, sports skills, academic skills) are targeted for development.

3. Typically paraprofessional implemented.
4. Intensive treatment settings such as summer treatment programs (9 hours daily for 8 weeks), and/or
school year, after-school, and Saturday (3 hours) sessions. See http://www.summertreatmentpro
gram.com for description.
5. Behavioral (contingent rewards and negative consequences) and cognitive behavioral (e.g., social
skills training, problem-solving training) integrated in the context of recreational activities.
strongly that parents will almost uniformly choose a nonpharmacological intervention as the first
treatment, and that they prefer low doses to higher doses (Pelham et al., 2000). In the MTA study,
75% of the children assigned to the behavioral treatment group (which got the kind of comprehensive
behavioral treatment shown in Table 9.3) were maintained without medication for the 14 months
of the study and made dramatic improvements in functioning—improvements as great as children
who were medicated by their family physicians (Conners et al., 2001; MTA Cooperative Group,
1999a; Pelham, 1999). Further, 62% of this group were being maintained by their parents without
medication and with continued positive functioning 1 year later—a full 18 months after their
behavioral treatment had ended (MTA Cooperative Group, 2004). For those who were being medi-
cated, the dose on which they were maintained was 43% lower than children in the medication-
only group of the study, 95% of whom were continually medicated. In contrast, children in the
combined treatment group—for whom medication was begun at the same time as behavior
therapy—were also medicated at a higher rate (95%) and at a dose approximately 37% higher.
Thus, when behavioral intervention is begun before medication in ADHD children, a substantial
portion of the population will be able to avoid medication, and those medicated will receive lower
doses. Given parental preferences for this approach, lowered risk of side effects, and the “do no
harm” credo, this would appear to be the sequence of choice.
Behavior modification needs to be multifaceted, involving parents, school, and child. Behavioral
interventions are conceptualized as the application of social learning theory to modify children’s
behavior by training parents and teachers to manipulate environmental antecedents (e.g., com-
mands), consequences (e.g., rewards, punishments), and contingencies (the relationship among
target behaviors, antecedents, and consequences) (Jacob & Pelham, 1999). Operant procedures,
that is, using negative (e.g., punishment) and positive (e.g., rewards) contingencies to reduce prob-
lem behaviors and increase adaptive behaviors, are behavioral strategies commonly used to modify
children’s behavior. Training parents and teachers to implement contingency management
programs is a clinical behavioral intervention that can be initiated and coordinated by primary care
practitioners or mental health practitioners working in collaboration with them. These treatments
range on a continuum of intensity from relatively lower (e.g., praise, daily report card) to higher
intensity (e.g., special education placement, time out). Comprehensive treatment must also include
a child-focused component—difficult to do in a primary care setting, but necessary for the important
domains of academic functioning and the development of appropriate peer relationships.
Behavioral Parent Training

The purpose of parent training is to help parents manage their child’s behavior problems and
improve the family relationship. Table 9.3 lists the components of comprehensive parent training.
The procedures are flexible enough to enable parent training to be conducted by a trained parapro-
fessional, nurse, or mental health or school professional. Sessions are typically held in groups in
the evening or on weekends. Parents can meet in primary care offices, mental health clinics, or
schools. There are a number of existing comprehensive and effective parent-training programs
(e.g., Anastopoulos, 1998; Barkley, 1998; Cunningham, Bremner, & Secord-Gilbert, 1998; Forehand
& Long, 2002; Robin, 1998; Webster-Stratton, 1992; see Table 9.3 for downloadable materials for
parents, including how to construct a home-based daily report card).
Related to behavioral parent training, parental psychopathology may co-occur with the presen-
tation of child ADHD/ODD in primary care. Parental psychological problems, such as depression,
substance abuse, or ADHD are overrepresented in families of children with ADHD and ADHD plus
ODD/CD (Chronis et al., 2003); therefore, these problems often require concurrent treatment
focused on these difficulties, particularly since these problems may interfere with effective parenting
(i.e., Pelham, Lang et al., 1998; Sonuga-Barke, Daley, & Thompson, 2002). Physicians should refer
parents to mental health professionals for psychosocial (e.g., a course designed to help parents cope
with depression; Chronis, Gamble, Roberts, & Pelham, 2000) or psychiatric (e.g., stimulant medication
for treating adult ADHD; Evans, Vallano, & Pelham, 1994) treatment when parental psychopathol-
ogy is identified.
Classroom-Based Behavior Modification

Mental health professionals should adopt a consultative role in interacting with teachers about
possible classroom interventions. Behavior modification strategies in schools have been shown to
be effective across all three DBDs (Walker, Colvin, & Ramsey, 1995). Teachers can be trained
to implement a continuum of behavioral strategies within their classrooms (see Table 9.3), ranging
from school-wide discipline programs, through class-wide programs, to individualized programs
for a targeted child. An effective tool that should be part of all school interventions is a daily report
card (DRC; see Table 9.4). DRCs target individualized problems for children by setting behavioral
goals, establishing procedures for the teacher to monitor and give feedback to the children for those
problems, and providing feedback on a daily basis to parents on the children’s school performance
and behavior, for which parents provide a positive consequence at home (Kelley & McCain,
1995; O’Leary, Pelham, Rosenbaum, & Price, 1976). DRCs cost little, take little teacher time, and
can be highly motivating for the child. In combination with appropriate praise, commands, and
classroom/assignment structure, a DRC constitutes a level of school-based intervention that can
easily be coordinated by primary care staff or collaborators. A downloadable packet that a teacher
can use to establish a DRC with a parent is available (see Table 9.3). When this level of intervention
is insufficient, more intensive work with the classroom teacher (e.g., teaching him or her to implement
a point system) or placement in special education, if appropriate, typically yields improvement.
Materials are available that can facilitate the instruction of these behavioral techniques to
teachers (DuPaul & Stoner, 1994; Pfiffner, 1996; Walker et al., 1995; Walker & Eaton-Walker, 1991;
see Table 9.3 for downloadable materials for teachers, including instructions for creating a school-
based DRC).
Child Intervention
A typical child with ADHD, ODD, or CD will have areas of impairment and deficient competencies
in important areas (e.g., social skills, academic achievement) that cannot be addressed in an office
setting. The primary care provider must refer these patients to receive effective services that might
include academic tutoring or evidence-based peer interventions such as intensive summer treat-
ment programs (Pelham & Hoza, 1996; Pelham et al., in press). Such interventions are essential
components of comprehensive care to target domains that are important predictors of long-term
outcome, such as academic achievement or social relationships. Table 9.3 lists the components of
such child-focused interventions.
TABLE 9.4 Sample School Daily Report Card

Child’s Name: _____________________ Date: ______________________
Special Language Arts Math Reading SS/Science
Follows class rules (no more than 3 rule
violations per period). Y N Y N Y N Y N Y N
Completes assignments within the
designated time. Y N Y N Y N Y N Y N
Completes assignments at 80% accuracy. Y N Y N Y N Y N Y N
Complies with teacher requests (no more
than 3 instances of noncompliance per
period). Y N Y N Y N Y N Y N
Gets along with peers (no more than
3 instances of teasing per period). Y N Y N Y N Y N Y N
OTHER
Follows lunch rules (2 or fewer
violations). Y N
Follows recess rules (2 or fewer
violations). Y N
Total Number of Yeses.
______________.
Teacher’s Initials: __________________
Comments:
Combined Behavioral and Pharmacological Treatment

For ADHD, when behavioral interventions have produced improvement but it is insufficient,
parents have a choice between more intensive behavioral treatment (e.g., special education placement)
and adjunctive medication. If a parent opts for medication, then a structured assessment can be
conducted by the primary care professional working with school staff or a mental health
professional. This assessment will yield a good starting dose for a long-term medication regimen.
Over the past 20 years, a methodology for assessing individual medication response has been
developed within the context of a summer treatment program (Pelham, 1993; Pelham, Bender,
Caddell, Booth, & Moorer, 1985; Pelham, Aronoff et al., 1999, Pelham, Gnagy et al., 1999) and
extended to other analogue settings (Pelham, Gnagy et al., 2001) and natural settings (MTA Coop-
erative Group, 1999a; Pelham, Hoza et al., 2002). This methodology is a short-term, double-blind,
placebo-controlled medication assessment in which different medication doses (e.g., 0.3 mg/kg meth-
ylphenidate and 0.6 mg/kg methylphenidate) or different stimulants and placebo are randomized
on a daily basis for a period of 4–5 weeks. We outline the procedures for an outpatient medication
assessment in Table 9.5. A medication assessment in which medication is randomized by day and
not by week reduces the confounding error variance associated with fluctuations in daily routines
or other potential confounds (e.g., having a substitute teacher for a week) that may occur during an
assessment. Error variance is distributed across all medication conditions rather than confounded
with one condition, allowing for readily interpretable results.
It is well known that response to stimulant medication varies within and across children,
depending on a number of factors, including the child’s referring problems, the setting, the
presence of a concurrent behavioral treatment, the time of day, and the nature of task demands
TABLE 9.5 Medication Treatment Guidelines for Practitioners Working in Primary Care for the Management
of a Child With ADHD, ODD, or CD
1. Implement only following the development and implementation of an ongoing behavioral treatment
program.
2. Conduct an initial controlled assessment of various doses/types of stimulant medication to select start-
ing dose (instructions and instruments listed below are available, see “Conducting an Outpatient
Medication Assessment and Ratings” at http://wings.buffalo.edu/adhd).
3. Decide on the type of medication to be included in the assessment. Start with either methylphenidate
or amphetamine-based compounds. If the initial medication is ineffective, try the other stimulant
molecule before other drug classes.
4. Determine need for t.i.d. dosing or long-acting medication (e.g., Concerta, Adderall XR) based on
child’s impairment across settings. Only use t.i.d. dosing or long-acting medication if there is docu-
mented impairment in the after-school setting. Likewise, prescribe medication for weekends only if
there is documented impairment during weekend activities.
5. Explain the medication assessment procedures to child, parents, and teachers.
6. Emphasize to parents and teachers (if dosing at school) the necessity of standardized medication
administration times.
7. Use the school-based DRC or other feasible indicators of impairment to objectively quantify the effec-
tiveness of medication.
8. Have nurse or mental health professional randomly assign medication conditions to days of the week,
and place capsules in daily pill minder to be used at home or school.
9. Have parents and teachers complete the Pittsburgh Side Effects Rating Scale daily.
10. Be alert for low base-rate but serious side effects, such as tachycardia and motor tics.
11. Inspect data of percentage of daily report card targets met on each condition, along with side effects
ratings.
12. Determine if clinically significant gains were obtained on medication days versus placebo days.
13. Select the effective minimal dose to complement the behavioral intervention, leaving room for
improvement (e.g., the child’s daily report card remains challenging) and minimize side effects.
14. Monitor monthly using DRC or CIRS as indicator of functioning to adjust dosages both up and down
and justify continued need; monitor height and weight.
15. Withdraw medication annually to document continued need; continue until no deterioration occurs
when withdrawn.
(Pelham & Smith, 2000). Therefore, deciding whether stimulant medication confers beneficial
effects for a given child is a complex undertaking, and in order to answer the question of whether
medication benefits an individual child, a physician must systematically investigate the effectiveness
of medication in the setting and on the measures in which the child is impaired. Because medica-
tion is typically being prescribed for school problems, obtaining objective, detailed information on
medication response from the child’s teacher is paramount. Research has shown the DRC (already
established for the child as part of his or her behavioral treatment) to be a sensitive measure of
medication effects, surpassing the utility of more expensive, time-consuming measures of medica-
tion effectiveness such as daily teacher ratings or classroom observations (Pelham, Hoza et al., 2002;
Pelham, Gnagy et al., 2001).
For children who need medication, combined treatment has an incremental benefit over and
above a pharmacological or behavioral treatment alone (e.g., Conners et al., 2001; Pelham &
Waschbusch, 1999). For example, there are several reasons to speculate that long-term maintenance
of treatment effects might be improved with a combined intervention. Children with ADHD
exhibit impaired academic and social adjustment. To the extent that these skills are necessary for
successful long-term outcome, treatment that includes a behavioral intervention focusing in part
on building competencies in academic and social domains should improve the long-term outcome,
which would not be achieved with medication alone. Similarly, to facilitate maintenance of behav-
ioral treatment effects, the intervention should be such that it can be continued by the child’s
parents or teachers for a protracted time. Because the addition of a low dose of stimulant medica-
tion enables relatively greater effects to be achieved with less restrictive and more natural behavioral
programs (e.g., Abramowitz, Eckstrand, O’Leary, & Dulcan, 1992), a combined treatment may be
more likely to be maintained by parents and teachers over time.
In addition to the above-mentioned benefits of combined treatment, parents and teachers over-
whelmingly prefer combined behavioral and stimulant medication interventions to medication
alone. Adding behavioral treatment to medication dramatically reduces dissatisfaction with medica-
tion and doubles strong satisfaction among parents (Pelham et al., 2000). Furthermore, combined
treatments typically result in the greatest normalization of functioning (e.g., Conners et al., 2001;
Klein & Abikoff, 1997; Swanson et al., 2001). Finally, and importantly, combined treatments enable
dramatic reductions in the dose of medication that is needed to yield optimal benefit—with reduc-
tions from 25–75% across a number of studies (Carlson, Pelham, Milich, & Dixon, 1992; Pelham
et al., 1980; Vitiello et al., 2001). Given possible long-term side effects associated with high doses of
medication, reduction in dose is a desired outcome.
Prevention Protocols
Along with facilitating treatment (e.g., tertiary prevention), primary care providers are in the
perfect position to implement primary and secondary preventative measures, given their regular
contact with families and established clinical relationships. Researchers have highlighted the
importance of early intervention for children with ADHD and ODD/CD, to prevent and redirect
negative developmental trajectories that might result in more serious psychosocial problems
(Conduct Problems Prevention Group, 1999; Tremblay, LeMarquand, & Vitaro, 1999). Primary
prevention for DBDs can begin as soon as parents sit down in the physician’s waiting room.
Handouts, informational packets, books, and videos on evidence-based assessment and treatment
can be made available to waiting parents. In addition, primary care physicians should be aware of
upcoming developmental transitions for all children (e.g., increased tantruming for 2 to 3 year olds;
beginning of middle school) and use these opportunities to prepare and educate all parents for
potential difficulties (e.g., instruct parents of toddlers on the proper use of time out, encourage
parents to teach their beginner–middle school children how to use a daily assignment notebook).
Secondary prevention may be handled in a similar fashion.
Costs of Effective Services for ADHD and ODD/CD

Clearly, families of children with ADHD use medical services at a greater rate and therefore have
greater medical expenditures than families of children without ADHD. For example, in a birth
cohort in Rochester, MN, the median costs of health-care expenditures for children with ADHD
were twice that of children without ADHD (the median cost for children with ADHD was $4,306
versus $1,944 for those without ADHD), and contributing to this increased cost, children with
ADHD were more likely to have visited emergency rooms and receive other inpatient and outpa-
tient health services (Leibson, Katusic, Barbaressi, Ransom, & O’Brien, 2001). Kelleher (1998) has
presented information from a Medicaid database showing that children with ADHD in western
Pennsylvania were being provided mental health treatments with an average annual cost of $1,800 in
1994, comparable to the annual medical treatment of another chronic childhood problem—asthma.
Given the low rate of utilization of evidence-based behavioral treatments in practice, it is unlikely
that this $1,800 went to appropriate treatments other than medication, which is considerably less
expensive than this cost.
Exacerbating the cost of these expenditures is the observation from surveys of doctors that only
half the children in primary care settings are reported to receive care compatible with practice
guidelines for ADHD treatment (Hoagwood et al., 2000), and those children are only receiving
medication, not behavioral treatment, arguably an ineffective treatment for ADHD in the long run.
For children with only ODD or CD, for whom medication is not indicated, the likelihood is that
they receive no treatment in primary care.
The behavioral intervention (or the combined intervention) that we have outlined above—all of
the components, including the intensive 8-week summer treatment program—is provided in our
clinic (in 2003 dollars) for $4,000 per child per year. Without the summer program, the cost is on
the order of $1,500 per year. If effective, evidence-based treatments can reduce health-care utiliza-
tion, it is arguable that at least the low intensity behavioral intervention (parent training, school
consultation, and medication) could be provided in a very cost-effective manner. For a managed
care organization that spends $100/child/month for a primary care visit and the cost of Concerta,
one of the newly approved medications for ADHD and the current market leader, the cost savings
from having 75% of the ADHD children unmedicated could be put toward effective psychosocial
treatments.
Consider the cost of special education and out-of-district placements for a school district. Special
education typically costs two to three times what regular education costs. In addition, out-of-district
placements (for the most disturbed children—almost always diagnosed as ADHD/ODD/CD) cost
$20,000 to $30,000 per child per year. A school district that can prevent a high proportion of
ADHD/ODD/CD children from being placed in special education or out-of-district placements by
providing appropriate behavioral interventions (accompanied by low dosages of medication when
necessary) in the regular classroom setting will achieve dramatic cost savings. The combined savings
to the community across agencies and systems (e.g., health, education, justice) from effective treat-
ments for ADHD and ODD/CD should be considerable even if more intensive evidence-based
interventions are implemented for a substantial portion of the indicated children.
Finally, to the extent that providing effective interventions can prevent the development of later
problems (e.g., substance abuse, criminal behavior) that are more costly to society and to the indi-
vidual and family, effective intervention in primary care has the potential to not only be cost effective
but also save an enormous amount of resources for society. Such an evaluation has not yet been
conducted but is needed to justify the services that are called for in current guidelines.
Monitoring Functioning and Quality Assurance

In Tables 9.2 and 9.3, we have addressed guidelines for ongoing monitoring of treatment response.
An example of a simple and idiographic mechanism for monitoring and tracking functioning in
school was described above, the DRC. The utility of the DRC for monitoring and evaluating the
effectiveness of medication in the short term has already been described. Indeed, the DRC is also
useful for monitoring functioning in the individual child’s most important domains of dysfunction
(that is, the targeted behaviors on the DRC) over the long term. In contrast to the typical lack of
communication among the school, parents, and the primary care provider, the DRC prompts daily
contact and parental monitoring of the child’s school functioning. This daily information affords
parents the opportunity to reward and praise a child for daily successes and meeting successive
approximations toward behavioral goals, and permits rapid response if behavior deteriorates
(e.g., three days in a row of no behavior targets met might prompt a teacher meeting to determine
an aspect of the intervention that needs to be modified). The DRC percentage of goals met is also
easily graphed, and it provides parents with an ongoing assessment of their child’s functioning that
can be shared at appointments with the mental health professional and primary care physician,
who can evaluate the child’s progress at a glance. In addition, simple rating scales such as the CIRS
described above can be repeated monthly, with parents bringing them in at appointment times.
Although other monitoring systems focus on the DSM symptoms of ADHD and ODD/CD
(e.g., AAP & NICHQ toolkit), the simple idiographic approach of the DRC is more efficient and
arguably more valid (Pelham, Gnagy et al., 2001; Pelham, Hoza et al., 2002).
An Illustration of Comprehensive Treatment in Primary Care

To provide an idea of how these clinical procedures might be applied in a primary care setting,
consider a prototypical child with ADHD/ODD. Prior to an office visit, the child’s mother and
teacher complete a standardized rating scale of ADHD/ODD symptoms and an impairment rating
scale. These ratings are mailed in ahead of the visit, and an office staff member may then review the
forms and begin to formulate appropriate treatment recommendations. After a diagnosis and
evidence of significant psychosocial impairment are established, a nurse or mental health profes-
sional works with the child’s teacher to develop and implement a DRC like the one in Table 9.4. The
parents would be referred to a standard, manualized parenting program run by a nurse (perhaps in
the office waiting room in the evening or on the weekend) or a local mental health professional.
Finally, to address the child’s peer relationships, the child would be enrolled in a program to address
academic achievement and peer relationships, such as a Saturday or summer treatment program
(Pelham & Hoza, 1996). At the next visit, the child’s parent would be asked to bring back the school-
based DRC and complete the same rating scales completed before the initial visit. If the child is still
exhibiting psychosocial impairment based on parent and teacher reports on these measures, the
behavioral interventions should be modified. Should the problems persist past the initial modifica-
tion of the programs, the programs could be modified again (i.e., to make them more intensive), or a
school-based medication assessment might be initiated (coordinated by a member of the office staff
or local mental health professional). After a stable course of treatment is established, physicians then
schedule frequent checkups to prevent relapse and maintain treatment gains.
Summary
ADHD and the other disruptive behavior disorders are prevalent; chronic mental health problems
account for more than half of the referrals for pediatric psychosocial services, special education
services, and mental health services. All contemporaneous guidelines and informed opinions indi-
cate that ADHD, ODD, and CD need to be conceptualized as chronic mental health disorders. This
necessitates a reformulation of treatment approaches for these disorders to be in line with other
serious, chronic disorders such as autism and schizophrenia. Treatment for these three disruptive
behavior disorders must be intensive, must be planned for the long term, and must include fre-
quent check-ups and programs for relapse prevention, as we have outlined in Tables 9.2 and 9.3. It
has been argued, for years, that the treatment of ADHD should take place in primary care settings
(Christopherson, 1982). Sanders and Ralph (2001) noted that
practitioners are frequently asked by parents for advice regarding their children’s behavior.
Family doctors are the most likely source of professional assistance sought by parents of
children with behavioral and emotional problems and are seen by parents as credible sources
of advice (p. 26).
Given that doctors are de facto care providers for these children, they must be educated and well
versed in the ways to effectively evaluate and treat children with behavior disorders (Costello, 1986;
Higgins, 1994). Because it would afford early identification and early intervention, an emphasis on
identifying and treating these disorders in the primary care setting would be consistent with many
of the recommendations made in the recent Report of the Surgeon General’s Conference on Children’s
Mental Health (U.S. Public Health Service, 2000).
Conducting a functional assessment of the child’s impairment in daily life functioning should be
the thrust of assessment. Standardized rating scales, obtained from parents and teachers, along with
interviewing the parents, will identify areas of impairment and targeted behaviors for treatment.
Behavioral treatments should be employed as the first-line treatment for ADHD, ODD, and CD,
with combined pharmacological and behavioral treatments for ADHD and co-morbid children
being an effective and recommended adjunctive alternative if a child fails to show acceptable levels
of improvement with only behavioral strategies in place. It is important that, as in any chronic
disease model, treatment be ongoing. Primary care practitioners should stress the maintenance of
treatment and provide systematic follow-up, involving the evaluation of treatment responsiveness
and assessment of emerging problems that may lead to treatment nonadherence or failure. In
following the evidence-based guidelines to assessment and treatment of ADHD and ODD/CD,
primary care practitioners can effectively reduce current impairment, build competencies in
important functional domains, and prevent the progression of behavior problems into more
serious disorders and dysfunction.
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Chapter 10
Providing Integrated Care for
Smoking Cessation
ELIZABETH V. GIFFORD, KATHLEEN M. PALM, AND ANDREA DILORETO
Cigarette smoking presents a costly challenge for smokers, health-care professionals, and policymakers.
Of the 17 million smokers who yearly make a serious attempt to quit, only 1.3 million are successful
(Fiore, 1992; Hatziandreu et al., 1990). Even if no one were to begin smoking from this time
forward, tobacco would still cause 10 million deaths worldwide within the next 20 years (see
Warner, 1998). In the United States smoking remains the leading cause of preventable illness and
death (U.S. Department of Health and Human Services, 2004). Tobacco-related diseases have
reached “epidemic” proportions (Cinciripini, Hecht, Henningfield, Manley, & Kramer, 1997). Fur-
thermore, treatment for smoking-related illnesses costs over $50 billion annually, and indirect costs
from lost time at work and disability cost an additional $47 billion–50 billion (AHRQ, 1996;
USPHS, 2000).
According to the Agency for Health Care Policy and Research 1996 Smoking Cessation Guideline:
Smoking cessation interventions offer clinicians and health care providers their greatest
opportunity to improve the current and future health of all Americans (U.S. Department of
Health and Human Services [DHHS], 1989).
As described by Orleans (1993) and others, the majority of current smokers will never enroll in
smoking treatment but will see a primary care physician each year. The primary care setting is thus
the obvious vehicle for dissemination of smoking cessation interventions. For this reason, the U.S.
Department of Health and Human Services (USDHHS) states that it is crucial that physicians and
health-care delivery systems consistently identify, document, and treat every tobacco user seen in a
health-care setting (Fiore, 2000).
The tobacco control field has led the way toward integrating behavioral health issues in medical
settings (Davis, 1988). Efforts to encourage integrated care for smoking have been undertaken at
the federal and state policy levels, and among nonprofit and for-profit health-care organizations.
These efforts have begun to bear fruit. For example, based on its surveys, the National Committee
for Quality Assurance (NCQA), in its 2000 report on the “State of Managed Care Quality,” states
that the average percentage of adult smokers who received advice to quit smoking from a medical
201
professional increased from 1996 to 1999 by 4.3% (from 61% to 65.3%). This 4.3% improvement
(on average) means more than 1,000 additional smokers were advised to quit, and 33 smokers quit
smoking per their health plan. These numbers represent a financial savings of $68,000 per plan.
In 1999, approximately 6 million current or recent American smokers received advice from their
physicians to quit. Although this figure represents an improvement over previous years, there is still
a long way to go. According to NCQA, the lowest performing managed care organizations (MCOs)
reported physician advice rates of 56%; the top performers reported rates of 73%. If all Americans
were enrolled in top-quality plans with 73% rates,“28 million smokers would receive such advice,
715,000 more smokers would quit, and the health care system would save over 1.5 billion per year”
(NCQA, 2000, pp. 10–11).
In this chapter we present state-of-the-art smoking cessation treatments, methods for delivering
smoking treatment in primary care settings, and guidelines for integration at the organizational
level. Tobacco cessation benefits from a relatively long history of integration efforts. Perhaps the
most important of these lessons is the fundamental value of integration: systematic methods for
integrating medical and behavioral concerns can result in profoundly meaningful health-related
behavior change—change for the individual smoker, for the health-care delivery organization, and
for the larger community.
Smoking-Related Health Risks

In a report recently released by the Centers for Disease Control (CDC) and Prevention (2000),
chronic diseases emerged as the leading cause of death in the United States. In 1996 alone, an estimated
2.3 million people died from various forms of cardiovascular disease, cancer, and respiratory/
pulmonary disorders. Cumulatively, these chronic diseases account for almost 70% of all deaths.
Smoking has been identified as a primary or secondary risk factor in virtually all the aforemen-
tioned diseases, and has, as a result, become the leading preventable cause of death and disability in
the nation. The CDC reports that approximately 430,000 deaths each year can be directly attributed
to cigarette smoking, a number that exceeds the combined number of deaths attributable to AIDS,
alcohol, drug abuse, car crashes, murders, suicides, and fires. Half of all regular tobacco users will
die from smoking-related complications (CDC, 2000).
Cigarette smoking and its link to emphysema and lung disease are well known, yet the harmful
effects of smoking are widespread and extend beyond the respiratory system. Cardiovascular diseases
have been identified as the number one cause of death, a category including coronary heart disease,
cerebrovascular disease, atherosclerotic disease, and hypertension, and the risk of developing one of
these disorders increases with the number of cigarettes smoked and the duration of smoking
(McBride, 1992). Smoking has also been implicated in the development of a number of types of
cancer, and according to the National Institute on Drug Abuse, rates of death from cancer are twice as
high among smokers as nonsmokers, with rates increasing to four times as high with heavy smokers
(NIDA, 2001). Smoking has been established as a major cause of lung, laryngeal, oral, and esophageal
cancers; 80–90% of deaths from these cancers are attributable to smoking. Lower, yet significant per-
centages of deaths due to bladder, kidney, pancreatic, and stomach cancers (20–50%) are likewise
attributable to smoking. In all cases, a smoker’s risk of cancer is increased anywhere from 2 to 10 times
that of a nonsmoker (Newcomb & Carbone, 1992). In addition to contributing to the development of
cardiovascular diseases and cancer, cigarette smoking is the primary cause of pulmonary illnesses
including chronic obstructive pulmonary disorder (COPD), chronic bronchitis, and emphysema.
Smokers also experience an increased incidence of respiratory infections (Sherman, 1992).
Female smokers are particularly vulnerable to a number of health problems. In addition to the
aforementioned diseases affecting all smokers, women who smoke have an increased risk of developing
Providing Integrated Care for Smoking Cessation • 203
cervical cancer, and for women taking oral contraceptives, the risk of coronary heart disease increases.
Pregnant women who smoke not only increase their own risk for disease, but also adversely affect the
health of their infant or unborn fetus. Secondhand cigarette smoke is considered to be a risk factor for
conduct disorders in childhood and causes SIDS and low birth weight. Women who smoke while preg-
nant also increase their risks of spontaneous abortion and ectopic pregnancy (USDHHS, 2004).
Despite the long-term damage caused by smoking, quitting and staying quit can markedly
improve a smoker’s health. If a smoker quits smoking before the age of 50, he or she doubles the
chance of living for the next 15 years (CDC, 2000). The risk of cardiovascular disease is dramati-
cally reduced within 6 months to 2 years of abstinence. A pregnant woman who stops smoking
early in pregnancy reduces her risk of complications to the same level as a woman who has never
smoked (USDHHS, 1990).
According to the American Lung Association (1991), within 20 minutes of smoking the last
cigarette, blood pressure, pulse rate, and temperature of hands and feet return to normal levels.
Nine months after quitting, carbon monoxide and oxygen levels in the blood become normal, lung
capacity increases up to 30%, and the body’s overall energy level increases. Furthermore, 5 years
after quitting, the risk of lung cancer for the average smoker (one pack per day) decreases from
137 per 100,000 to 72 per 100,000. The message is clear: quitting smoking significantly reduces
health risks.
Empirically Supported Smoking Treatments

Several different pharmacological and behavioral treatments for smoking cessation have been
found effective. Choosing the appropriate treatment or treatments for a particular smoker may
depend on the smoker’s preference and the person’s readiness to change. In this section, we describe
effective pharmacological smoking cessation treatments and psychosocial interventions.
Nicotine Replacement Therapy

Nicotine replacement therapy (NRT) has been well documented as an efficacious and safe treat-
ment for smoking cessation. The nicotine transdermal patch, polacrilex gum, nasal spray, and
vapor inhaler have been shown to attenuate withdrawal symptoms experienced by smokers by
slowly reducing the overall levels of nicotine in the body (Hatsukami & Mooney, 1999). In addition
to offering relief from withdrawal, some forms of NRT, specifically the nasal spray, gum, and vapor
inhaler, may also produce effects that are perceived by some smokers as benefits of smoking, including
arousal or relaxation (Benowitz & Peng, 2000).
Although the patch, gum, nasal spray, and vapor inhaler show comparable overall outcomes,
they differ in their availability, administration, immediacy of effect, and side effects, factors that
should be taken into consideration when choosing an NRT (see Fiore, 2000). Both the nicotine
patch and gum are available over the counter (OTC) in a variety of dosages. Sold as Nicoderm or
Nicotrol, the patch is available in 21/14/7 mg, 15 mg, and 22/11 mg doses, and is administered once
a day for either 16 or 24 hours, providing a steady level of nicotine throughout the day. The nicotine
gum, under the brand name Nicorette, is available in 2 and 4 mg pieces and is administered either
according to craving or at a fixed interval. The gum should be chewed slowly at first and then held
between the lip and gum so that optimum nicotine absorption can occur (AHCPR, 1996).
The nasal spray and vapor inhaler are available only through prescription under the trade name
Nicotrol. Among the various forms of NRT, nicotine delivery via the nasal spray more closely
approximates that of smoking, with continine levels reaching roughly 30% of smoking levels
(Schneider et al., 1995). The nasal spray delivers 1 mg of nicotine in each dose (0.5 mg per nostril)
and is administered ad libitum. The nicotine inhaler, a plastic tube with a perforated plug containing
4 mg of nicotine, delivers nicotine via a puff or inhalation, with each cartridge containing enough
nicotine for approximately 80 puffs (AHCPR, 1996).
Because each delivery system is unique, it is possible that combining two forms of NRT may
further improve success rates. It has been shown that the combined use of the patch and the
gum can significantly increase abstinence rates when compared with either treatment alone. One
study reported a 50% higher abstinence rate at the end of the treatment period when those using a
16-hour active patch along with active gum were compared with those receiving only the active
patch. Although there was no significant difference between the two groups at the 6-month follow-
up, the investigators did find that the amount of time before relapse was significantly longer for
those receiving both active treatments (Kornitzer, Bousten, Dramaix, Thijs, & Gustavsson, 1995).
It is important to note that while there is a great deal of evidence supporting the clinical utility of
NRT in the treatment of smoking, the ability of each of these treatments to work alone varies and
each treatment appears to more effective with the addition of some form of behavioral interven-
tion. Virtually all the studies considered included psychosocial interventions in addition to the
medication, and many authors acknowledge and advocate group and individual support, both brief
and intensive, as an adjunct to NRT (AHCPR, 1996; Cinciripini & McClure, 1998; Hjalmarson,
Franzon, Westin, & Wiklund, 1994; Silagy, Mant, Fowler, & Lodge, 1994).
Nonnicotine Therapies
Although NRT has continued to be the most frequently used pharmacological treatment for smoking
cessation, many studies on nonnicotine medications are ongoing. Currently, only bupropion, cloni-
dine, and nortriptyline have sufficient empirical support for inclusion in the AHCPR guideline.
Nonnicotine medications are thought to aid in smoking cessation by lessening withdrawal symp-
toms, mimicking the beneficial physiological effects of smoking, or creating an aversion to smoking
(Cinciripini & McClure, 1998). Antidepressants have begun to emerge as the most promising
nonnicotine medications for smoking cessation.
Bupropion SR. Presently, sustained release bupropion (bupropion SR) is the only nonnicotine
medication recommended as a first-line treatment by the AHCPR and approved by FDA for the
treatment of smoking. Although the precise mechanism of action for this antidepressant has not
been identified, it is thought that bupropion SR (a dopamine reuptake inhibitor) may mimic some
neurochemical effects of nicotine, including the release of dopamine, noradrenaline, and serotonin
(Benowitz & Peng, 2000).
Empirical support for this medication is derived from two large-scale controlled trials (Hurt et
al., 1997; Jorenby et al., 1999). In both studies, patients reported a number of side effects, the most
prominent being dry mouth and insomnia. In the Jorenby study, dropout rates were 12% and 11%
for the bupropion group and combined treatment group, respectively, while attrition was only 7%
in the patch group and 4% in the placebo group. The Hurt study reported three serious adverse
events linked to the higher dosage of bupropion SR. It should be noted that, as with the majority of
studies on NRT, these trials examining the efficacy of bupropion also included some form of behav-
ioral intervention. (Benowitz, & Peng, 2000; Jorenby et al., 1999)
Clonidine. The antihypertensive medication clonidine is recommended by the AHCPR only as

second-line pharmacotherapy to be used in the event that first-line medications, including NRT
and bupropion SR, are insufficient or ineffective for a patient. Clonidine can be administered either
transdermally or orally and should be taken before the quit date. Empirical support for clonidine
remains contradictory, but in a meta-analysis of nine studies, clonidine was reported to have out-
performed placebo, particularly when the patient was female (Covey & Glassman, 1991).
Because the FDA has not yet approved the use of clonidine as an aid for smoking cessation and
the adverse effects are frequent, it should be dispensed cautiously on a case-by-case basis under a
physician’s direction (AHCPR, 1996). In a review of studies of clonidine, adverse experiences were
reported by 23–92% of patients taking clonidine, the most common side effects being dry mouth,
sedation, and dizziness. Given the frequency of these adverse effects, it has been suggested that this
treatment be reserved for patients who experience intense agitation and anxiety when attempting to
quit smoking (Gourlay & Benowitz, 1995).
Nortriptyline. The tricyclic, antidepressant medication nortriptyline, like clonidine, is recom-

mended only as second-line pharmacotherapy for smoking cessation because of its lack of approval
from the FDA for this purpose and its potential adverse effects. In its review of treatments for
smoking cessation, the AHCPR found only two studies offering evidence in support of nortrip-
tyline. Both clinical trials reported that significantly higher abstinence rates were obtained with
nortriptyline when compared with placebo: 24% versus 12% and 14% versus 3%, respectively.
Nortriptyline did not effectively reduce withdrawal symptoms. Reported adverse effects included dry
mouth, lightheadedness, shaky hands, blurred vision, altered taste, drowsiness, and gastrointestinal
distress (Hall et al., 1998; Prochazka et al., 1998). According to Benowitz and Peng (2000), nortrip-
tyline blocks noradrenaline uptake in a manner similar to bupropion, thereby increasing the overall
level of noradrenaline; nortriptyline does not block dopamine reuptake but does block serotonin
reuptake. Due to the risk of serious adverse events, including myocardial infarction, arrhythmia,
and stroke, nortriptyline requires intensive patient screening and monitoring.
Psychosocial Treatments/Behavioral Interventions

The effectiveness of these pharmacological treatments increases significantly when they are
combined with behavioral interventions. Indeed, certain pharmacological interventions have been
tested primarily in combination with counseling. For example, it is an often-overlooked fact that
the two major studies that established bupropion SR as an empirically supported frontline inter-
vention included a behavioral counseling component (Hurt et al., 1997; Jorenby et al., 1999), and
that bupropion SR has not been studied as a stand-alone treatment. There is also a substantial body
of literature describing the efficacy of behavioral and counseling interventions alone (Antonuccio,
Boutilier, Ward, Morrill, & Graybar, 1992). It is important for medical personnel to familiarize
themselves with the behavioral options described below, as well as local resources for obtaining
these services if they do not already exist in-house.
Self-Help Interventions
Self-help materials such as pamphlets, manuals, and videos, are designed to increase smokers’
motivation to quit and to communicate cessation skills. These types of materials are appealing for a
number of reasons: high-quality intervention expertise can be widely distributed at a fairly low cost,
materials can be customized according to stage of readiness or demographic characteristic, and
smokers can adapt the program to their individual needs (Curry, 1993).
According to the AHCPR guideline, these materials, irrespective of media presentation, do not
appear to be particularly effective and are not recommended as stand-alone treatments for smoking
(AHCPR, 1996). Despite the lack of empirical support for self-help as a primary method of
treatment, these materials do appear to be somewhat beneficial for smokers who are less dependent
on nicotine and who are highly motivated to quit. The efficacy of self-help strategies can likewise be
augmented by tailoring materials to individual users and by the addition of telephone support or
counseling. In a study of over 3,000 smokers, Zhu and colleagues (1996) examined the extent to
which self-help interventions and telephone counseling facilitate smoking cessation. They found
significantly higher abstinence rates among those groups receiving single and multiple telephone
counseling sessions.
Behavioral Interventions
Smoking is a behavior that is, in large part, developed and maintained through learning processes.
Interventions and techniques addressing the behavioral determinants of smoking have long been
empirically supported (Shiffman, 1993). Specific behavioral techniques are directed toward helping
smokers identify and change behaviors that lead to smoking, reinforce nonsmoking, and teach
avoidance and relapse prevention skills (APA, 2001). Among the behavioral techniques, aversive
techniques, scheduled smoking, contingency management, cognitive behavioral therapy, and
practical counseling and supportive care have gained the most empirical support.
Aversive smoking techniques create a conditioned aversive response by diminishing the pleasur-
able effects of smoking and inducing nausea or dizziness. Rapid smoking, rapid puffing, smoke
holding, and focused smoking all involve using cigarettes and smoking as aversive agents. In rapid
puffing and rapid smoking, clients puff on a cigarette every few seconds; in rapid smoking, the
client will actually inhale the smoke until the cigarette is finished or the client is unable to continue.
In smoke holding, the client inhales and holds the smoke in the mouth while continuing to breathe
through the nose. Focused smoking requires the client to smoke at a slow and regulated rate (APA,
2001; Lando, 1993; Schwartz, 1992). These aversive techniques are effective, and they can be used
with clients for whom other interventions have not worked. In a meta-analysis of 62 studies esti-
mating the efficacy of counseling and behavior therapies, rapid smoking and other aversive tech-
niques produced abstinence rates of up to 19.9% (AHCPR, 1996).
Scheduled smoking places smokers on fixed interval schedules linked to preexisting smoking
levels. This technique gradually and systematically reduces the amount of nicotine in the smoker’s
system, weaning the smoker from nicotine without the use of nicotine replacement therapy. In
addition, fixed schedules may reduce stimulus control over smoking, as smokers learn to perform
behaviors other than smoking during times they previously smoked. The amount of time between
cigarettes is also gradually and systematically increased. In one particular study, scheduled smoking
produced higher abstinence rates when compared with abrupt cessation and uncontrolled reduc-
tion, and also reduced tension, fatigue, withdrawal, and urges to smoke (Cinciripini et al., 1995;
Cinciripini & McClure, 1998).
The implementation of rewards and punishment in a system commonly referred to as contin-
gency contracting or contingency management has likewise been supported empirically. In this
intervention, smokers typically gain or lose money based on their current smoking status. During
the course of treatment, abstinence earns rewards, while relapse earns punishment. Contingency
management appears to be most effective during the treatment period, and long-term efficacy has
yet to be empirically supported (APA, 2001). It has been shown that different schedules of
reinforcement can produce differential abstinence effects. Incorporating relapse contingencies
appears to improve effects. A progressive increase in magnitude of reward with a reset contingency
for relapse appears to be more effective than a fixed magnitude or progressive increase without a
reset contingency (Roll & Higgins, 2000).
Cognitive behavioral treatment is defined by efforts to help clients identify and anticipate
situations that predispose them to smoke. Clinicians problem-solve with patients by helping them
recognize internal and external states that threaten their abstinence and help them learn how to
cope effectively with these states by imparting skills. Specifically, clients learn how to avoid or cope
with these triggers through behavioral or cognitive techniques. Methods of behavioral coping
include replacing the behavior with another, escaping the situation, or using skills to manage the
triggers to smoke. Cognitively, clients can identify and challenge maladaptive beliefs or habitual
patterns of thinking. Clients who engage in problem-solving and relapse-prevention training have
achieved significant sustained abstinence rates; therefore, these methods are recommended as a
core component of any behavioral intervention (AHCPR, 1996; Lando, 1993).
Strong social support from friends and family is often predictive of abstinence from smoking,
yet attempts to implement social support in empirical settings have proven elusive (APA, 2001;
Lando, 1993 Lichtenstein, Glasgow, & Abrams, 1986). Supportive care from a clinician, however,
can significantly enhance quit rates. By expressing feelings of concern about the patient’s smoking
status, providing information about smoking and quitting, and encouraging the patient to talk
about his or her feelings, a clinician can have a positive influence on a patient’s smoking status.
With supportive care and practical counseling, abstinence rates of approximately 15% can be
achieved (AHCPR, 1996).
Using several techniques in concert appears to increase efficacy, outperforming no-contact
controls and yielding 6-month abstinence rates of 20–25% (AHCPR, 1996; APA, 2001; Baillie,
Mattick, Hall, & Webster, 1994; Glasgow & Lichtenstien, 1987; Lando, 1993; Law & Tang, 1995;
Schwartz, 1992). The most effective multimodal, or multicomponent, therapies appear to incorpo-
rate skills training for both quitting and maintaining abstinence. It has also been suggested that
multimodal treatments may enhance cessation rates by allowing clients to tailor the treatment to
their own particular situation (Lando, 1993).
Although the aforementioned psychosocial interventions are frequently considered inconvenient
or time consuming, their importance for the treatment of smoking cannot be underestimated. The
AHCPR concluded that person-to-person contact can have a significant impact on cessation rates,
and as treatment intensity increases, so does treatment effectiveness. This dose-response relation-
ship is evident in as many as 43 studies, and for this reason, behavioral interventions have been
identified as a necessary and effective component of any smoking cessation treatment program
(AHCPR, 1996).
Assessment and Treatment in the Primary Care Setting

The literature is very clear: simple smoking cessation interventions performed by physicians in
primary care settings have profound effects. Providing a short message and advice to quit results
in 1-year quit rates of 6% (Anderson & Wetter, 1997). More frequent physician contacts
or combining physician messages with self-help or pharmacologic agents increases this number to
22% (Houston Miller & Barr Taylor, 2000). According to Robinson, Laurent, and Little (1995),
physicians are more likely to provide smoking cessation information to patients when physicians
consistently inquire about smoking status. The very process of identifying smokers can serve not
only as an integral part of a medical assessment, but also as an intervention (Fiore, et al., 2000).
In practice, according to the National Ambulatory Medical Care Survey (n = 1,558) (Jaén, Stange,
Tumiel & Nutting, 1997), physicians tend to conduct smoking assessments only with patients who
are at risk because of other chronic illnesses (e.g., cardiovascular disease). Unfortunately, this selec-
tion criteria means the vast majority of smokers are not advised by their physicians to quit smoking.
Smoking Status
One concern about implementing an effective screening system is the practicality of adding another
assessment to the limited time constraints with which physicians’ offices have to work. Identifying
patient smoking status, however, can be easily integrated into standard procedures. Including
smoking status as a vital sign increases the rate of identifying smokers and assisting patients with
smoking cessation (Fiore et al., 1995; Robinson et al., 1995). The AHCPR clinical guidelines for
smoking cessation provide an example of how to incorporate the assessment of smoking status into
standard practice by treating it as a vital sign (see Table 10.1). They suggest that clinicians assess
every patient to determine whether the patient currently uses, never used, or used to use tobacco.
Nicotine Dependence
Assessment of nicotine dependence can be important in determining an appropriate treatment
program for smokers. Research has found that highly nicotine-dependent smokers are likely to
need more intensive therapy (Orleans, 1993). The CAGE questionnaire, the “Four Cs” test, and the
Fagerstrom Tolerance Questionnaire are all efficient self-report tools commonly used to assess
addiction (Etter, Vu Duc, & Perneger, 1999; Prokhorov et al., 2000; Rustin, 2000). These assess-
ments inquire about patients’ feelings of control over their own behavior, withdrawal symptoms,
impact of smoking on their thoughts and feelings, and acknowledgment of consequences related to
the addictive behavior. In particular, the Fagerstrom scale assessments have been found to predict
success at smoking cessation and which smokers will benefit from nicotine gum or nasal spray
(Fagerstrom & Schneider, 1989; Pomerleau, Majchrzak, & Pomerleau, 1989). Simply asking
whether the first cigarette of the day is smoked within 30 minutes of awakening is a simple but
reliable index of nicotine dependency (Fagerstrom, 1978; Pomerleau et al., 1989).
Smoking History
This assessment should include smoking rate, years smoked, desire to quit, stage of quitting
(Prochaska & DiClemente, 1983), and past quit attempts. The majority of smokers have made at
least one attempt to stop smoking (Fiore, 2000). Although most smokers who try to quit are no
longer abstinent 1 year after quitting, each attempt increases their chance of quitting completely
(Fiore, 2000). With each effort to quit, the smoker learns which skills are effective or ineffective. In
order for the physician to help identify an effective cessation intervention for the client, it is impor-
tant to assess circumstances related to past quit attempts; for example, past reasons for quitting,
cause of relapse, length of time patient remained abstinent, and prior cessation strategies.
Environmental and Psychosocial Variables

Identifying rewarding aspects of smoking can be very useful in tailoring treatment for patients.
Although it is important to ask the patient about past smoking behavior and quit attempts, it is use-
ful and often informative for clinicians to inquire about current smoking behaviors and the func-
tions smoking currently serves, for example, “Where do you smoke?” “When do you smoke?” and
“Why do you smoke?” These questions should be used to identify external triggers (e.g., “When I’m
with friends and we’re out drinking”) and internal triggers (e.g., “I smoke because I’m stressed”).
There are several smoking functions commonly endorsed by patients (Rustin, 2000):
1. The act of smoking often provides the patient with physical stimulation (i.e., warmth, taste,
feel in fingers, puffing, smoke, moving hand to mouth, etc.).
TABLE 10.1 Vital Signs

Blood Pressure: __________________________________
Pulse: __________________ Weight: ________________
Temperature: ___________________________________
Respiratory Rate: ________________________________
Tobacco Use: (circle one) Current Former Never
2. Many patients perform rituals that become habits that are difficult to change.
3. Patients often identify who they are by their smoking behavior. For example, they have
learned to identify themselves as “rebellious” or by the brand of cigarette they smoke.
4. Many smokers report smoking cigarettes in an effort to achieve emotional relief.
The function of smoking may also vary depending on the patient’s social context. Social support
has been shown to be a major predictor of smoking cessation (Lichtenstein et al., 1986; Orleans,
1993). Smokers who have friends and family who are supportive of their quit attempt are more
likely to remain abstinent. Therefore, identifying the smoking status of people in the patient’s
environment and their willingness to support the client in current and past quit attempts should be
assessed. Reducing contact with smokers, enlisting the support of smokers (i.e., asking them to
smoke outdoors, not to offer cigarettes, etc.), or encouraging significant others to join them in quit
attempts are all helpful when smokers are part of the individual’s social network.
Assessment of additional psychosocial factors may be useful in making a prognosis of whether
patients will achieve and sustain cigarette abstinence (Orleans, 1993). Patients with greater self-
esteem, effective coping skills, more confidence about their ability to quit, positive health habits,
manageable life stress, and good self-management skills have a better prognosis. Furthermore,
smokers who abuse alcohol or drugs have a more difficult time quitting smoking. Thus, clinicians
should also assess whether patients use alcohol or other substances.
Readiness to Change
A great deal of smoking cessation literature has focused on the predictive utility of assessing
patients’ readiness to change (Dijkstra, De Vries, & Roijackers, 1999; Pine, Sullivan, Sauser, &
David, 1997; Prochaska & DiClemente, 1983; Rohren, et al., 1994). Prochaska and DiClemente
(1983) have described a model that outlines stages of willingness to change among smokers. These
stages include precontemplation, contemplation, preparation, action, and maintenance. Based on
the patient’s stage of change, health-care providers can implement appropriate interventions that
are likely to move patients into the next stage (Pine et al., 1997; Velicer, Prochaska, Rossi, &
Snow, 1992). Research suggests that patients who are not considering quitting may benefit from
different treatment strategies than those who identify with other stages of willingness to change
(Pine et al., 1997). For example, when confronted with a precontemplator, the role of the physician
becomes motivational, and the goal is to get the patient to consider quitting. Patients in the prepara-
tion stage may benefit from more specific advice regarding treatment, and patients in the action or
maintenance stage will benefit from discussion of relapse potential and problem-solving aimed at
relapse prevention.
Despite the fact that some patients are motivated and ready to change their behaviors, there
are common barriers that make it difficult to quit, including for example, fears of weight gain and
withdrawal symptoms. Identifying reasons and barriers for smoking cessation can be useful when
motivating the client to quit (AHRQ, 2003). In addition to assessing for reasons and barriers, moti-
vation can be enhanced by inquiring about patients’ treatment preferences.
Biochemical Markers
Patients’ self-reports of smoking are often adequate; however, some patients provide inaccurate
reports of their smoking. Inaccurate reports could be due to reasons ranging from memory
problems to shame about smoking. If the physician desires accurate monitoring of the patient’s
smoking, then there are devices that can be used to obtain objective readings that reflect smoking
behavior. Some of these biological indices include carbon monoxide level readings and serum level
testing. In addition to providing objective records of smoking, showing patients changing carbon
monoxide levels can provide motivational enhancement. For example, carbon monoxide levels can
be measured quickly and easily by expelling breath into a device that reflects smoking over the past
several hours (Secker-Walker, Vacek, Flynn, & Mead, 1997; Velicer et al., 1992). Nicotine and
cotinine levels can be measured in blood, saliva, and urine (Jarvis, Tunstall-Pedoe, Feyerabend,
Vesey, & Saloojee, 1987). CO readings assess tobacco use over the past 24 hours, nicotine level
assesses tobacco use over the past few hours. Cotinine, a metabolite of nicotine, is sensitive to
smoking in the past week and provides a better assessment of total daily nicotine exposure (Secker-
Walker et al., 1997).
Integrated Treatment Models

The success of smoking cessation and prevention programs depends on the integration of assessment
and treatment strategies into systems that are acceptable and effective for staff and patients. Effec-
tive systems can vary in form but most share certain essential components: repeated assessment of
smoking status and motivation to quit, identification of barriers, and multiple follow-up contacts.
The AHRQ Clinical Practice Guidelines suggest treatment strategies that health-care providers
should be prepared to use with patients who are willing to quit smoking (Fiore et al., 2000). The
first strategy, commonly referred to as the “5 As,” involves the following:
• Ask the patient about his or her smoking status.

• Advise the smoker to quit.
• Assess willingness to quit.
• Assist those who are willing to quit.
• Arrange follow-up appointments to help prevent relapse.
Research suggests that practicing these guidelines will help identify and treat smokers more
effectively. Research also shows that using more “As” improves outcomes. Health Plan Employee
Data Information Set (HEDIS), released by the National Committee for Quality Assurance
(NCQA), is a set of guidelines for performance measurement in health care delivery. HEDIS 3.0, the
third version of HEDIS, was released in 1998. Asking and advising smokers to quit, as emphasized
by HEDIS 3.0, has been called the “2A model” (Hollis et al., 2000). Although this is certainly better
than nothing, and may serve as a motivational enhancement for some precontemplative smokers,
the full 4A model generates exponential improvement in cessation rates. Hollis says:
Delivering brief advice to 60% of the smokers who see a clinician each year across the country
might generate about 126,000 additional quitters over and above the spontaneous rate. If we
increase the simple advice rate to 90%, we would produce something like 189,000 additional
clinician generated quitters, which would be a substantial achievement. But suppose, once
each year, clinicians advised 90% of smokers and that, for the half of these smokers who are at
least considering quitting at any given time (“contemplators” in Prochaska’s model),
clinicians or their staff also provided 10 minutes of actual cessation counseling and assistance.
The AHCPR meta-analyses estimate that 10 minutes of cessation assistance yields a much
higher 2:4 odds ratio. This would yield about 756,000 additional quitters per year or a six-
fold increase in the number of clinician generated quitters over current practice. My point
here is that the third and fourth As in the 4A model really do matter, and we need to over-
come the very real barriers that are preventing the delivery of systematic and comprehensive
tobacco intervention in most primary care settings today (pp. 18–19).
Many smokers report that they are not ready or willing to quit smoking at this time. There are
crucial steps health-care providers can take in order to increase patients’ motivation to stop smoking.
The AHCPR panel (Fiore, 2000) suggested a treatment strategy referred to as the “5 Rs”: relevance,
risks, rewards, roadblocks, and repetition. The health-care provider should encourage the patient to
identify reasons why smoking cessation is relevant to him or her. In addition, the clinician can assist
the client in clarifying the potential risks of not quitting and the rewards he or she might experience
from quitting. Further, it is often useful to predict roadblocks, or barriers, that the patient might
encounter when trying to stop smoking. Identification of barriers can assist the patient and the
clinician in including treatment strategies into the cessation program that are helpful when encoun-
tering those roadblocks. Finally, these strategies should be repeated whenever these patients visit
the clinic.
Orleans (1993) describes a stepped-care model for the treatment of nicotine dependence in
medical settings. This model is based on Prochaska and DiClemente’s (1983) multistage model,
described above, with the addition of a “relapse and recycling” stage “with those who slip or relapse
after achieving abstinence returning to any earlier stage” (Orleans, 1993, p. 150). Because accom-
plishing sustained abstinence often requires multiple quit attempts, health-care environments
should provide multiple intervention opportunities, and every health-care visit should be viewed as
an opportunity to help the smoker take “the next step.”
Orleans’s (1993) model starts with establishing a facilitative environment. This includes preparing
the organizational environment and systems, including establishing a “smoking cessation coordina-
tor,” and identifying and resolving barriers to implementation (e.g., lack of time among primary
care physicians and dentists means that much of the assessment and treatment must be delegated
once the smoker is identified). Once the environment is established, all patients’ smoking status is
assessed, including a brief smoking and quitting history. In addition, assessment should occur
repeatedly. Failures to quit should be treated as “practice” and used to provide more information
regarding the individual’s smoking assessment needs. This information should be summarized in
the progress notes.
The next stage in the model involves enhancing motivation, that is, moving smokers to the next
stage. Personal health risks and benefits should be addressed, and if possible, linked to existing
medical conditions and delivered by the primary care provider. Barriers and fears regarding quitting
should be explored if patients fall into the majority category of “contemplators” who are consider-
ing quitting. Importantly, this educational intervention should include strong advice to quit.
Orleans suggests the following statement: “As your physician (dentist) I strongly advise that you
stop smoking. If we can give you some help, are you willing to give it a try?” (1993, p. 154).
If smokers are willing to make a commitment, they should be directed to treatment. Patient pref-
erence regarding treatment should be included, and pharmacological and counseling preferences
and options should be discussed. Minimal self-help interventions in combination with a follow-up
phone call provide a starting point, and there are a number of self-help materials oriented to partic-
ular populations, including women, African-American and Hispanic smokers, older smokers, and
teen smokers. Patients who feel over 70% sure they will be successful at quitting on their own likely
will benefit from simple self-help materials (Houston Miller & Barr Taylor, 2000). For many smok-
ers, quitting on their own is most preferred, and repeated minimal contact interventions involving
primary care providers are the most efficient method. The best method for the individual patient
will depend on his or her history of success or failure and the particular triggers he or she describes.
Make sure that you or your office staff has information on community resources, including program
costs, methods used, and a contact person.
Indicators for more intensive treatment include patient preference, a history of many prior treat-
ments or self-help failures, higher levels of nicotine dependency, and a lack of support, skills, or
motivation. Formal treatment programs, involving either counseling or medication, or, preferably,
both (Fiore et al., 2000), should be provided. Such treatment should be offered again if treatment
failure occurs. Frequently, relapsed patients may become, for a time, “precontemplators,” unwilling
to make the commitment to try again. Patients should not be reintroduced to formal treatment
options, including medication, until they are willing to initiate a quit attempt or program. Finally,
at the same time that quit dates are established, follow-up contacts should be discussed and
planned with all those in the contemplation stage of change or above. Such discussions alone
improve quit attempts and quit successes. Follow-up should consist of a phone contact or a return
office visit, along with personalized self-help mailings (e.g., notes accompanying motivational or
advice pamphlets).
Organizational Systems/Systems Changes

More than half the U.S. population, and up to 85% of privately insured individuals, are enrolled
in managed care plans. For example, in 1996, 100 million Americans were enrolled in employer-
sponsored HMOs and PPOs (CFAH, 2000). The Surgeon General’s Report on Treating Tobacco Use
and Dependence states: “research shows clearly that systems-level changes can reduce smoking prev-
alence among enrollees of managed health care plans” (PHS, 2000, p. 1). The U.S. Public Health
Service (PHS) guideline recommends the following strategies:
• Every clinic should implement a tobacco-user identification system.

• All health care systems should provide education, resources, and feedback to promote pro-
vider interventions.
• Clinical sites should dedicate staff to provide tobacco dependence treatment and assess the
delivery of this treatment in staff performance evaluations.
• Hospitals should promote policies that support and provide tobacco dependence services.
• Insurers and managed care organizations (MCOs) should include tobacco dependence
treatments (both counseling and pharmacotherapy) as paid or covered services for all
subscribers or members of health insurance packages.
• Insurers and MCOs should reimburse clinicians and specialists for delivery of effective
tobacco dependence treatments and include these interventions among the defined duties
of clinicians (p. 2).
Many exemplary, integrated, smoking cessation treatment programs exist, including Blue Cross-
Blue Shield of Maine, Benefits Health Plan, Network Health Plan, HealthPartners, and others
(e.g., see PHS, 2000). One of the best examples of a comprehensive approach to smoking prevention
and cessation is Seattle Group Health Cooperative (GHC). Through the development of an inte-
grated system, with the goal of decreasing smoking prevalence within its enrolled population, GHC
increased participation in its smoking cessation programs tenfold, from 180 per year in 1991 to
1,500–2,000 per year since 1993 (McAfee & Thompson, 1998). They also increased identification of
smoking status from 30% to over 85% in their primary care clinics, and doubled physician’s
documentation of advice to quit among physicians. Seventy-one percent of GHC patients who
smoke in postvisit surveys reported that their physicians talked to them about smoking during their
office visit. Their legislative lobbyist worked to support passage of a state law banning cigarette
vending machines and other community-based interventions including media campaigns. As a
result of these changes, over the past decade smoking prevalence among GHC members has
decreased from 25% to 15% (a 10% drop), versus statewide decreases from 25% to 23% (only a
2% drop).
Managed Care Organizations and Smoking Cessation Interventions

What interventions produced these commendable results? There are several key strategies, all of
which begin with a single factor: put smoking cessation efforts in the organizational mission. It has
been argued that health maintenance organizations (HMOs) or managed care organizations
(MCOs) have a financial interest in targeting smoking prevention (e.g., McAfee & Thompson,
1998; Yox, 1995). Given the extraordinarily deleterious health effects of tobacco consumption, such
interests seem obvious. For example, numerous studies have shown that quitting smoking results in
decreased use of inpatient and outpatient health-care services, as well as reducing risk for cardio-
vascular and cardiopulmonary disease, low birth-weight infants, and work-related absenteeism
(USDHHS, 2004). Smoking cessation programs pay for themselves in 3 or 4 years by reducing hos-
pitalization utilization alone (Wagner, Curry, Grothaus, Saunders, & McBride, 1995).
However, it is important to acknowledge that in for-profit MCOs, there are factors working
against integration of the prevention agenda, particularly the rapid cycling of members through
some MCOs, and a focus on short-term cost decreases by some MCO managers (McAfee &
Thompson, 1998). McAfee and Thompson (1998) recommend that the organization develop a
division for prevention that is entrusted with certain functions: (a) emphasizing the marketing
value of prevention services and the public-relations benefits of adopting these strategies; and
(b) emphasizing the “higher” goals of the organization, namely, improving and saving lives, not just
reducing costs. Just as necessary therapeutic interventions such as appendectomies are unquestion-
ingly provided, critical prevention interventions such as smoking cessation should be automatically
administered.
Influencing organizational leaders requires knowledge about the cost effectiveness of programs,
knowledge about program implementation, and knowledge about the particular integration oppor-
tunities available within the health plan system (Krejci, 2000). Dacey (2000) states:
Support at all the different levels of the organization, from the top leadership down, is criti-
cal. A successful program involves laying this groundwork. Endorsement from the chief exec-
utive officer, the quality structure leadership, the clinic manager, and the medical chief, as
well as individual providers and their teams, must be gained. Gaining this support starts with
creating a sound evidence based argument as to why the program is central to the health of
the patient (p. 2).
Fortunately, the smoking cessation literature provides well-articulated evidence on smoking and
health care, and well-developed, easily accessible guidelines for evidence-based practice. For exam-
ple, the American Association of Health Plans’ Addressing Tobacco in Managed Care: A Resource
Guide for Health Plans (2001), and the U.S. Department of Health and Human Services’ Treating
Tobacco Use and Dependence (2000c).
With leadership support for a prevention effort, the next step is to set goals. These goals can
include numbers of enrollees in smoking treatment programs, membership smoking rate reduc-
tion, reduction of cardiac or other disease events, numbers of smokers receiving advice to quit, and
so forth. Once organizational goals are defined, it is necessary to develop systems to monitor
progress and implementation; for example, systems to identify and document smoking status, to
provide treatment, and to evaluate outcomes. There are several simple ways of monitoring or flag-
ging client files to prompt providers to assess for smoking status. First, once a patient’s smoking
status has been identified, a sticker corresponding with the appropriate status should be placed on
the folder. For example, Etter, Rielle, and Perneger (2000) found that placing “Smoker” stickers on
patients’ charts increased the likelihood that physicians would advise smokers to quit smoking.
Second, a stamp with spaces to track smoking status and other useful smoking information can be
printed on the patient file or, similarly, a tracking note inserted into the file. Fiore and colleagues
(1995) found that tracking smoking as a vital sign on progress notes significantly increased the rate
of identifying smokers, advising them to quit, and assisting with smoking cessation. These data sys-
tems must be in place before programs are implemented. Building on existing organizational data
systems should occur wherever possible.
Managers, clinicians, and researchers who have been involved in dissemination continue to
report their real-world experiences in the literature. Several general principles guiding successful
smoking cessation systems implementation are as follows:
1. Keep it simple. For example, use tobacco chart stickers and vital sign stamps. It is imperative
to consider the time demands of busy practice environments (Dacey, 2000, p. 30). Every
step, including documentation of smoking status and interventions and referrals to smok-
ing counselors, should be easy and should fit efficiently into office flow (Hollis et al., 2000).
2. Delegate time-intensive tasks. Provide systems so busy physicians can refer patients to special-
ists within the organization, such as trained RNs, or specialist programs within the organi-
zation that provide individualized treatment (Dacey, 2000, p. 31).
3. Provide centralized support/staffing and dedicated funding for this staff (Dacey, 2000; see also
Krejci, 2000, p. 34). Orleans (1993) suggests each primary care practice or practice setting
select a tobacco cessation coordinator who is responsible for integration of nicotine depen-
dence treatment into the clinic or organization. Where members can access the services
directly, it is important to notify the primary care provider (and members must be
informed that such notification will occur). In network model health plans, a centralized
and integrated delivery system is recommended because it increases efficiency with office
requirements (e.g., a common toll-free number for participants in different markets), staff
training (i.e., telephone counseling staff are in the same place), and staff supervision and
support.
4. Design programs that use follow-up and permit consistent contact with staff responsible for
delivering services or maintaining systems. According to Krejci (2000), “consistent ‘one-on-
one’ coaching by a trained cessation specialist is paramount to the members’ success, and
we believe this is the reason we have maintained quit rates above 40% at one year” (p. 34).
Counselors can be health education specialists (i.e., those with undergraduate or graduate
degrees in health education or public health), registered nurses, social workers, crisis coun-
selors, substance abuse counselors, or others.
5. “Measure outcomes, evaluate the processes, and provide feedback” (Dacey, 2000, p. 31). Three
key areas to evaluate are utilization, member/provider satisfaction, and quit rates (Krejci,
2000). It is important to establish automated systems that permit audits and develop or utilize
existing quality feedback reports, such as patient outcomes, electronic chart reviews, num-
bers of smokers identified, patient satisfaction.
6. “Identify individuals at all levels accountable for measurable outcomes” (Dacey, 2000, p. 31).
Program evaluation should assess “implementation, data collection, staff, and operational
integrity and effectiveness” (Krejci, 2000, p. 35). For example, medical assistants responsible
for chart stickers, providers responsible to intervene and document intervention in chart,
quality implementation team responsible to oversee clinic performance should be
monitored (Dacey, 2000, p. 31). Accountability should be built into programs from the
beginning.
7. Provide incentives for change. For example, certain health plans offer financial incentives to
member clinics based on targeted goals such as smoking status identification and docu-
mented cessation counseling (Solberg, 2000, p. 37–38). Clinics can pass along these
“bonuses” to staff delivering services to encourage compliance with 5A protocols. Perfor-

mance reviews are another important means of creating incentives (Hollis et al., 2000).
Incentive measures and recognition should also be kept simple and meaningful (Isham,
2000).
8. Execute “ongoing, multiple promotion” to the membership in order to increase utilization
(Krejci, 2000, p. 35). Krejci states, “We have learned that it is necessary to apply multiple
promotion strategies—repeat your efforts and often. Consider multiple methods of promo-
tion such as targeted mailings, newsletters, brochures, and publications, open enrollments,
health fairs, ‘on hold’ phone messages, and public presentations. Send a brochure to a
smoker identified through a health questionnaire. Target high risk populations such as
members with diabetes, cardiovascular disease, or pregnancy through hospitalizations,
pharmacy, or claims data” (p. 35).
9. Cover the cost of cessation programs to reduce patient barriers to treatment (Dacey, 2000; Krejci,
2000). Complete versus partial coverage has been proven to increase treatment utilization
rates among patients (PHS, 2000). Small co-pays such as $20 may not function as barriers,
but noncoverage of nicotine replacement will significantly reduce the number of enrollees.
Coverage may also function as a “carrot” (Krejci, 2000, p. 33–34), and eligibility can then be
contingent on compliance with in-person or telephone counseling, for example, nicotine
replacement only provided to those who also fulfill their counseling.
Choosing the System for Your Office

Although many smoking prevention and cessation programs have proven to be effective in decreas-
ing rates of smoking, the cost-effectiveness of implementing such programs is a concern for most
health-care providers today. Two outcomes that are of particular interest to providers are total
financial cost and cost of the treatment per life-year saved. The financial cost of treatment includes
the cost of the resources consumed by smoking cessation treatments; for example, personnel, facili-
ties, equipment, supplies, and medications (Yates, 1996). Cost of treatment per life-year saved is a
cost-effectiveness ratio of the cost to the desirable outcome, which is improved health status and
quality of life.
Cromwell and colleagues (1997) assessed the cost-effectiveness of the 15 smoking interventions
recommended by the AHCPR clinical guidelines. Analyses were based on recommended resources
inputs found in the AHCPR report. Researchers combined three counseling interventions for
primary care clinicians (minimal, brief, and full) and two counseling interventions for smoking
cessation specialists (individual intensive and group intensive) with or without transdermal nico-
tine and nicotine gum. The researchers found that, in general, greater spending on interventions
yielded more net benefit. Specifically, more intensive interventions were related to lower costs per
life-year saved. Furthermore, full or intensive counseling plus the nicotine patch resulted in greater
quit rates and more life-years saved (Cromwell et al., 1997). Other studies have found that using the
patch as an adjunctive treatment to brief counseling resulted in better health and lower costs per
life-year saved when compared with brief counseling alone (Stapleton, Lowin, & Russell, 1999).
Nielson and Fiore (2000) analyzed the cost-effectiveness of the nicotine patch versus sustained-
release bupropion, minimal counseling plus placebo, and the combination of the patch plus
bupropion SR. These researchers assessed costs from an employer’s perspective and accounted for
absenteeism, medical care and workers’ compensation costs, and lost productivity in their analyses.
Results indicated that bupropion SR was more cost-beneficial than the patch, minimal counseling
plus placebo, and the patch plus bupropion. In this study, minimal counseling plus placebo cost less
than bupropion but also had a significantly lower quit rate than the bupropion alone.
Buck, Richmond, and Mendelsohn (2000) assessed the cost-effectiveness of integrating assess-
ments of readiness to change with behavioral interventions and NRT. The researchers provided
informational booklets to smokers who were assessed as precontemplative or contemplative. The
booklet for precontemplative smokers included information about smoking and an invitation to
return to the health-care provider to discuss quitting. The contemplative booklet also included
information about smoking but also presented a brief motivation interview. Finally, prepared
smokers received information on quitting, three visits for behavioral consultation, and advice on
using the nicotine chewing gum. Buck and colleagues found that the integration of assessing
readiness to change, behavioral interventions, and nicotine chewing gum was more cost-effective
than self-help manuals and behavioral interventions alone.
In sum, implementing any smoking cessation intervention seems to provide at least some small
net benefit (Nielson & Fiore, 2000). Studies suggest, however, that a combination of counseling and
pharmacological interventions results in more impressive quit rates and greater cost-effectiveness.
Smoking and Public Policy

Integrative efforts in the smoking cessation field are not limited to jointly delivered medical and
mental health care. Tobacco control efforts demonstrate integration in the broadest sense, uniting
regulatory, educational, clinical, and community health efforts. Since 1964, when the first connec-
tion between smoking and lung cancer was made, the changes in social norms and public policy
have dramatically decreased the nation’s rate of smokers, from over 42% to the current rate of
approximately 23% (MMWR, 2004). The national peak occurred in the early 1960s. Since then, the
surgeon general’s reports, the World Conferences on Smoking and Health, broadcast advertising
bans, the nonsmokers’ rights movement, increases in federal cigarette taxes, and other national
factors have contributed to the dramatic reduction in adult per-capita cigarette consumption
(USDHHS, 1999).
The Federal Drug Administration (FDA), as described by Koop, Warner, and others (see
Henningfield, 2000, p. 4), has tried to combat the fact that “it is easy to get the disease, hard to get
the treatment” (Henningfield, 2001, p. 4). The FDA’s tobacco rule addressed the susceptibility of
nicotine addiction by (a) establishing that nicotine is a drug, and cigarettes and smokeless tobacco
products are drugs and drug delivery systems (FDA, 1995), and (b) designing a program to reduce
nicotine access to young people (e.g., by preventing sales to youth, by refusing to permit advertising
in youth-oriented publications, etc.; FDA, 1996). However, on March 21, 2000, the U.S. Supreme
Court ruled that nicotine regulation does not fall under the FDA’s jurisdiction, preventing the imple-
mentation of the FDA’s efforts to reduce youth exposure to nicotine (American Medical Association,
2001). This ruling effectively passes the burden of prevention to the states.
According to the 1992 Synar amendment, states are required to establish and enforce laws
prohibiting the sale of tobacco to anyone under 18. In addition, the Substance Abuse Mental Health
Services Administration (SAMHSA) issued the Synar Regulation, which requires states to conduct
unannounced, random inspections of state tobacco vendors, and establish annual target rates mov-
ing toward a goal of an inspection failure rate of less than 20% by the year 2003. Current ongoing
funding for substance abuse prevention and treatment through SAMHSA may be denied to those
states failing to achieve their annual targets.
One of the most effective means of reducing smoking among smokers of all ages is increasing
excise tax rates. For example, Oregon passed a voter-approved measure to increase cigarette excise
taxes by 30 cents (to 68 cents per pack), and to implement new prevention programs (CDC, 2000).
These measures reversed a 4-year trend of increased smoking rates and lowered rates by 11.3%.
According to the CDC’s Morbidity and Mortality Weekly Report (USDHHS, 1999) “a 10% increase
in the price of cigarettes can lead to a 4% reduction in the demand for cigarettes” (CDC, 1999,
p. 989). California, Massachusetts, and Arizona have also passed voter initiatives (these initiatives,
perhaps not coincidentally, bypass heavily lobbied state legislatures) to increase state tobacco taxes
and develop tobacco prevention programs. As a result, “tobacco use rates in adults and youth have
declined in these states, relative to use rates in the nation as a whole” (Henningfield, 2000, p. 5).
Summary
Integrating smoking treatment into the primary care setting is an essential step in reducing smoking
and its human and economic costs. Integration efforts in the smoking field provide important
lessons in integrated behavioral health care and the evolution of organized behavioral health-care
practices. Summarized, these lessons include the following. First, good intentions are not enough.
Busy primary care providers will put out visible fires and will not focus on behavioral correction or
prevention. Second, systems need to be put in place that “make visible” the importance of these
interventions and trigger their provision. Third, implementing these systems requires thought and
effort. Provision of feedback (for all personnel involved in delivery) is essential, particularly as the
effects of these interventions are often cumulative and delayed, and health-care providers can
become discouraged by what they perceive as a lack of efficacy. In addition, change requires effort,
and feedback provides extra incentives. Fourth, the MCO, the community, and the state and federal
governments can be vital partners in the integration mission. Promoting health through behavior
change improves the lives of all members of a community or organization, and leaders need contact
with this data. Last but not least, the most important lesson for smoking cessation and the larger
behavioral health-care community is that integration works. Assessing for and intervening in smok-
ing behavior is an extremely productive use of time and resources in primary care settings. We have
the knowledge and the means to make a difference.
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Chapter 11
Infertility
NEGAR NICOLE JACOBS
Most individuals grow up with romantic illusions of getting married and starting a family at a time
of their choosing (Galst, 1986). For many, becoming a parent is a developmental milestone that
signals adult social status, as well as normality and sexual adequacy. On the societal and biological
levels, there may be an expectation that productive members of society will propagate in order to
ensure continuity and survival of the species. So strong is this cultural expectation that most family
members ask newly married couples when they plan to have children and how many children they
plan to have as opposed to whether they plan to have children. Given this individual and cultural
context, few men or women are prepared for the shock of infertility. Dreams of having children
playing within a house surrounded by a white-picket fence may be devastatingly shattered when the
diagnosis of infertility is made (Galst, 1986). Infertile individuals commonly report reactions of
anger, sadness, grief, guilt, and a sense of failure. In addition, there may be a sense of existential
crisis when previously held expectations about the future and meaning of parenthood are chal-
lenged by infertility.
The standard definition of infertility is the inability to conceive a pregnancy after 1 year of
engaging in sexual intercourse without the use of contraception (Leiblum, 1988). The time period
of one year was chosen because of the observation that approximately 25% of couples will con-
ceive within the first month of sexual intercourse without the use of contraception, roughly 60%
will conceive within the first 6 months, and around 80% will achieve pregnancy within the first
12 months (Olsen, 1990). A distinction is made between primary and secondary infertility: A couple
who has never been able to conceive a pregnancy is defined as having primary infertility (30% of
infertile couples), whereas a couple who already has previously conceived but is currently unable to
conceive is diagnosed as having secondary infertility (70% of infertile couples).
Reported rates of infertility vary between studies, but lie in a range of 8–16% of couples in the
United States (American Society for Reproductive Medicine, 1998; Menning, 1980; Mosher & Pratt,
1990). One population-based study found that at least one in six couples were infertile (Hull et al.,
1985). A number of factors have been hypothesized (Leiblum, 1988; Page, 1988; Stanton & Dunel-
Schetter, 1991) to be responsible for this high incidence of infertility: (a) declining age of onset of
sexual activity, (b) liberalization of sexual attitudes and behaviors; (c) rising numbers of sexually
transmitted diseases, which can damage reproductive organs; (d) increased exposure to toxic
221
environmental agents; (e) greater use of contraceptive devices, which can damage the reproductive
tract; (f) increased average age at first attempt to conceive; and (g) rising divorce rate and subse-
quent remarriage.
Biopsychosocial Theory of Infertility

Williams, Bischoff, and Ludes (1992) provide a biopsychosocial framework for understanding the
issues surrounding infertility. The authors posit that clinicians working with infertile couples must
be able to understand the medical, psychological, and social origins of the couple’s problems. They
maintain that these factors transact to produce the common sequelae associated with infertility,
including feelings of stress, depression, grief, marital difficulties, and social isolation.
Biological and Medical Aspects of Infertility

A basic understanding of the biological and medical aspects of infertility is essential in the develop-
ment and implementation of any treatment for infertile couples. Clinicians who are knowledgeable
about the medical aspects of infertility will be better able to understand the multiple stresses to
which infertile couples are subjected (Williams et al., 1992). Men and women are equally affected
by the biological causes of infertility (Menning, 1988). In 35% of cases the female partner receives
the diagnosis of infertility, while in 35% of cases the male partner is infertile. Infertility is a
combined problem between the male and female partners in 20% of the cases. The cause of infertility
is unknown in the remaining 10% of cases.
There are three primary medical causes of infertility in women. First, if a woman has hormone
problems or ovarian cysts, she may not produce or release mature eggs. Second, any scars or adhe-
sions of the fallopian tubes may obstruct delivery of the egg to the uterus. Finally, the fertilized egg
may not be able to properly implant itself into the uterine wall if the woman has structural abnor-
malities or hormone problems (Moghissi, 1978; Williams et al., 1992).
Male fertility relies upon the production and delivery of a sufficient quantity of sperm that are
normal, motile, and mobile (Leiblum, 1988). Therefore, causes of infertility in the male include
inadequate sperm production, structural abnormalities in the reproductive organs, and sexual
disorders, including erectile dysfunction (Keye, 1999; Leiblum, 1988; Williams et al., 1992).
Psychological Aspects of Infertility: The Experience of Infertility

The experience of infertility can be devastating for any couple who desires a child (Leiblum, 1988).
Most couples assume that they will be able to have children with a minimum of effort. When
attempts at conception are unsuccessful, couples are often faced, for the first time in their lives, with
failure and an inability to achieve a highly desired goal. Firmly held beliefs of being able to achieve a
desired goal if they work hard enough are challenged. If the couple believes that parenting is a sign
of adulthood, they may have to redefine their worldviews. Couples who have planned a future
around desired children may have to grieve the loss of the potential to raise their own children.
They must either adapt to the “transition to nonparenthood,” begin the difficult and often painful
process of medically assisted reproduction, or consider alternatives such as adoption.
The experience of infertility can take a significant emotional toll on both partners. In one study
(Freeman, Boxer, Rickels, Tureck & Mastroianni, 1985) of 200 couples undergoing in vitro fertiliza-
tion (IVF) treatment, researchers found that 49% of the women and 15% of the men considered
infertility as the most upsetting experience of their lives. Mahlstedt, McDuff, and Bernstein (1987)
found that 80% of their sample of infertile clients reported that their experience with infertility was
either “stressful” or “extremely stressful.” Other researchers have estimated that as many as 40% of
infertile individuals have significant emotional distress that carries the possibility of long-term
Infertility • 223
implications (e.g., Mahlstedt, 1985). In fact, infertility has been labeled a “biopsychosocial crisis” by
some researchers (Cook, 1987; Taymor, 1979).
Common reactions to the diagnosis of infertility include feelings of failure, guilt, shock, anger,
grief, depression, and a search for meaning. The failure to conceive may generalize to sexual insecu-
rity or even to feelings of failure as a human being. Individuals may wonder “Why me?” (McDaniel,
Hepworth, & Doherty, 1992). One infertility specialist reported that a high proportion of her
patients believed that their infertility was a punishment from God for a past sexual transgression or
other sin (Menning, 1988). Individuals may feel anger or resentment toward women who have
abortions. They may also feel jealous or envious of other women’s pregnancies.
Although the relationship between stress and infertility has been well documented, it remains
less clear whether high levels of stress are the cause or the consequence of infertility (Brkovich &
Fisher, 1998; Wright, Allard, Lecours, & Sabourin, 1989). A number of studies have investigated the
relationship between stress and physiological patterns in infertile patients. However, owing to
methodological shortcomings (e.g., correlational data only, lack of longitudinal designs, lack of
control groups) in these studies relating psychological distress to physiological patterns in individu-
als with infertility, no conclusions about causality can be made (Brkovich & Fisher, 1998; Wright
et al., 1989). Although there seems to be an association between extreme levels of environmental
stress and infertility, the relationship is tenuous in the majority of infertility cases (Leiblum, 1988).
It remains unclear whether stress resulting from infertility causes the above physiological changes,
or if existing physiological differences in certain individuals cause infertility. However, although the
specific links between psychological stress and physiological aspects of infertility are not yet delin-
eated, it is clear that the experience of infertility takes an emotional toll and taxes the psychological
resources of many couples (Stanton & Burns, 1999).
Infertile individuals may also feel a loss of control (McDaniel, Hepworth, & Doherty, 1992). Not
only have they lost the ability to conceive on their own, but they now have to expose intimate
details of their private lives as well as their private parts to doctors (Kraft, Palombo, Mitchell, Dean,
Meyers et al., 1980). Medical treatment for infertility can be invasive, painful, embarrassing, and
stressful. Many treatments for infertility involve close monitoring by vaginal ultrasound and blood
work, which are often assessed early every morning for up to 2 weeks per menstrual cycle (Domar,
1997). Thus, the impact of infertility on job or career plans can be profound (Domar, 1997). Early
morning monitoring can make women late to work, and women may have to switch to a job that
offers them the flexibility to pursue treatment. For women who have to travel as part of their jobs,
their travel plans may also have to be altered around times of ovulation, so as to ensure access to
insemination by their husbands. Women taking infertility medications may experience such side
effects as fatigue, nausea, bloating, headaches, hot flashes, irritability, depression, or anxiety
(Domar, 1997), which can have detrimental effects on daily functioning. The financial aspect of
infertility treatment may also be stressful for couples who cannot afford it. Neumann, Gharib, and
Weinstein (1994) concluded that the typical cost for a successful delivery with IVF ranges from
$44,000 to $211,940.
The experience of infertility has been likened to an “emotional roller-coaster” (Stanton &
Dunkel-Schetter, 1991). Couples may experience feelings of anxiety before ovulation, hopefulness
around the time of ovulation, and depression upon learning of a failure to conceive or a miscar-
riage. Hunt (1992) maintains that women are left in a state of “psychological pregnancy” for up to
2 weeks after embryo replacement from in vitro fertilization and may experience each lost embryo
as a miscarriage.
Feelings of depression can often accompany the psychological distress experienced by many
infertile individuals. However, studies investigating the level of depression experienced by infertile
individuals have found contradictory results. In a critical review of this literature, Greil (1997)
concluded that studies using standardized measures of depression were split almost evenly between
those finding moderately higher levels of depression among infertile individuals (e.g., Domar
Zuttermeister, Seibel, & Benson, 1992a) and those finding normative levels (e.g., Downey et al.,
1989). Greil (1997) further concluded that there was little evidence of clinically significant eleva-
tions among those studies describing elevated levels of depression.
The experience of depression may be associated with feelings of loss and grief (Lukse & Vacc,
1999). Menning (1980) argued that the most common, appropriate, and necessary reaction to a
conclusive diagnosis of infertility is grief. Losses due to infertility may include the loss of potential
children, the loss of a dream, the loss of genetic continuity, the loss of miscarriages, the loss of self-
esteem, the loss of security, the loss of control over one’s body, the loss of pregnancy experiences,
and loss of a sense that life is fair and predictable (cf. Cook, 1987; Mahlstedt et al., 1987; Menning,
1988; Williams et al., 1992).
Social Factors of Infertility
Impact on Couple. Medically assisted reproduction may also affect the couple’s relationship. Couples
may argue over the financial aspects of treatment or the course of treatment. They may have
differing reactions to infertility, and their coping mechanisms may clash (Mahlstedt, 1985). Infertility
treatment may also affect the couple’s sexual relationship. The prescription for scheduled inter-
course at specified points in the cycle may destroy spontaneous sexual contact or otherwise diminish
sexual pleasure. In addition, males may feel a demand to perform if they know there will be a post-
coital test immediately following intercourse.
Like any crisis, infertility has the potential to either cause problems in the relationship or unite
the couple. As such, researchers investigating the relationship between infertility and marital func-
tioning have produced mixed results. Some researchers have reported that infertility-related conflict
is common and can result in decreased marital functioning (e.g., Andrews, Abbey, & Halman,
1991), possibly through such negative reactions as anger, guilt, estrangement, blaming or feeling
blamed, lack of feeling supported, feeling misunderstood, and fearing a possible breakup of the
relationship (Epstein & Rosenberg, 1997; Mahlstedt, 1985). Other researchers have reported that
infertility does not adversely affect marital functioning (e.g., Daniluk, 1988; Downey et al., 1989).
However, Leiblum (1993) reported that couples undergoing in vitro fertilization rated their
relationships as better than average throughout the course of their treatment.
Although sexual dysfunctions have been implicated in infertility, Leiblum (1993) concluded that
only 2.6–5.0% of infertile individuals actually have any evidence of a sexual dysfunction. Moreover,
whereas sexual problems have been correlated with infertility in some studies (e.g., Andrews et al.,
1991), a critical review of the literature (Greil, 1997) concluded that the majority of studies of
sexual satisfaction have found few, if any, differences between infertile and fertile couples. However,
Tuschen-Caffier, Florin, Krause, and Pook (1999) noted that 50% of infertile women in their
sample did not have intercourse during the fertile period of their menstrual cycle, and that 14% of
couples did not know how to mark the fertile period correctly. These researchers found that rates of
live births could be increased by targeting adherence to a treatment regimen of timed intercourse
during the most fertile period of the menstrual cycle. Researchers found that helping couples
to differentiate between task-oriented sex during fertile days of the menstrual cycle and pleasure-
oriented sex during the rest of the cycle helped couples practice timed intercourse more reliably and
without decrements to sexual pleasure and satisfaction.
Social Stigma and Isolation. Greil (1991) describes the experience of infertile individuals living in
a fertile world. Couples with infertility are often asked private questions about when they plan to
Infertility • 225
have children or why they have not had children yet. Infertile couples often feel that these questions
are an invasion of their privacy, and make them feel like they are outsiders or failures (Greil, 1991).
When the pain of infertile couples is recognized, fertile individuals often treat it as trivial or incon-
sequential. They might give such advice as “just relax,” or “just take a trip and you’ll get pregnant,”
or they may minimize the complexity of treatment by saying such things as, “just do in vitro fertili-
zation.” Thus, infertile individuals have reported feelings of abnormality, rejection, abandonment,
and being outcast and unlovable (Domar, Seibel, & Benson, 1990). There have also been reports of
feelings of otherness, shame, guilt, failure, inadequacy, incompleteness, being devalued, and not
being whole (Whiteford & Gonzales, 1995). Furthermore, infertile women often report that they
feel they have deviated from societal norms and have broken gender roles by not having children
(Whiteford & Gonzales, 1995).
The feelings and experiences of infertile individuals may cause them to self-isolate in order to
minimize the possibility of being hurt. Individuals with infertility problems often avoid social gather-
ings, especially those related to fertility, such as baby showers, birthdays, communions, Bar Mitzvahs,
graduations, family reunions, and company picnics (Epstein & Rosenberg, 1997). In addition,
Epstein and Rosenberg (1997) have described a milestone-induced agoraphobia, in which infertile
individuals avoid any events that involve fertility or mark the passage of time.
Assessment
Given the variety of psychological sequelae of infertility, a thorough assessment is essential in order
to fully understand the presenting problem and select treatment targets. However, it must also be
remembered that many infertility patients feel the medical community is already intruding upon
their personal lives, and they may be reluctant to complete lengthy psychological assessment batter-
ies in addition. Thus, it is suggested that assessment of the psychological sequelae of infertility be as
brief as it is thorough. Brief assessment also lends itself well to repeated use in order to assess change
in psychological functioning over time. Patients will be much more likely to repeatedly complete,
and will be much less fatigued by, brief assessment batteries as opposed to lengthy batteries.
As noted above, common psychological sequelae of infertility include stress/anxiety, depression,
and marital difficulties. Standardized tools for the assessment of these sequelae exist in brief
versions. For example, the State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, Luschene,
Vagg, & Jacobs, 1983) is a psychometrically sound (Spielberger, Gursuch, & Luschene, 1970)
and widely used measure of subjective anxiety that comprises two sets of 20 statements describing
feelings of tension, worry, and apprehension. The state anxiety scale asks how the respondent feels
right now, and the trait anxiety scale asks how the respondent generally feels. All items are rated on a
4- point Likert scale. The shortened form of the STAI is a 6-item scale that produces scores similar
to those obtained using the full form, is sensitive to fluctuations in state anxiety, and has acceptable
reliability and validity (Marteau & Bekker, 1992). The standard self-report measure of depression in
the field is the Beck Depression Inventory (BDI; Beck & Steer, 1987, revised 1993). Although there
is no shortened form of the BDI, the full-length questionnaire consists of only 21 self-report items.
The BDI assesses the severity of depression in both normal and psychiatric populations. Questions
about the symptoms of depression are rated on a 4-point scale ranging from 0 to 3, with higher
scores indicating greater depressive symptomatology. The BDI has established reliability and valid-
ity (Beck, Steer, & Garvin, 1998). Meta-analysis of several studies has yielded a mean coefficient
alpha of 0.81 for nonpsychiatric subjects (Beck et al., 1998). The most commonly used measure of
marital adjustment/distress in the research literature is the Dyadic Adjustment Scale (DAS; Spanier,
1976). The DAS-7 (Hunsley, Pinsent, Lefebvre, James-Tanner, & Vito, 1995; Sharpley & Rogers,
1984) is a 7-item, abbreviated form of the original DAS, and has been found to have excellent
psychometric properties, including good internal consistency, criterion validity, and construct
validity (Hunsley et al., 1995; Sharpley & Cross, 1982; Sharpley & Rogers, 1984). The DAS-7 has
also been found to conserve, without loss of variance, the pattern of relations found between the
DAS and related constructs (Hunsley et al., 1995).
Despite the standardization and widespread use of the above measures, there are a number of
drawbacks and limitations in using such instruments in the population of infertility patients. First,
the above measures were not standardized for the infertility population. Thus, it is difficult to inter-
pret scores in the absence of norms specific to patients with fertility problems. Second, many com-
monly used instruments in the field were developed for and tested with psychiatric patients, not
medical patients. Accordingly, medical patients may interpret and respond differently to items than
psychiatric patients, especially with items assessing somatic symptoms. Third, studies assessing
psychiatric symptomatology in the infertile population have found mixed results, with most studies
concluding that patients with infertility do not meet criteria for anxiety or mood disorders. How-
ever, patients clearly report that the psychological sequelae of their fertility problems are disrupting
their lives. Thus, it may be that standardized questionnaires lack sensitivity to infertility-related
issues. Therefore, clinicians working with infertility patients should also consider infertility-specific
assessment tools.
The Fertility Problem Inventory (FPI; Newton, Sherrard, & Glavac, 1999) is a 46-item, self-
report measure of infertility-related stress. Subjects are asked to indicate their degree of agreement
with each item on a 6-point Likert scale. The FPI is a multidomain measure, producing scores on
the following scales: social concern, sexual concern, relationship concern, need for parenthood, and
rejection of child-free lifestyle. The FPI also produces a score on global stress. Newton et al. (1999)
found the scale to have acceptable reliability (internal consistency alpha ranged from 0.77 to 0.93
for all scales; test-retest reliability for the global stress scale was 0.83 for women and 0.84 for men).
In cross-validation with the BDI, STAI, and DAS, the FPI was found to have acceptable convergent
validity. Newton et al. (1999) also found that the FPI was more sensitive to the effects of infertility
on marital issues than was the DAS.
The Fertility Adjustment Scale (FAS; Glover, Hunter, Richards, Katz, & Abel, 1999) is a measure
of psychological adjustment to infertility. Adjustment is operationally defined as “the way in which
individuals acknowledge and process information about the course of their fertility problem and its
investigation, treatment, and possible outcomes” (Glover et al., 1999, p. 624). The scale is designed
to assess the extent to which subjects with infertility have come to terms with the possibilities of
having or not having a biological child of their own. Subjects indicate their level of agreement with
12 items on a 6-point Likert scale. The FAS was found to be normally distributed in the sample
of 100 infertility patients and was found to have acceptable reliability and validity (Glover et al.,
1999, p. 624).
The Infertility Questionnaire (IFQ; Bernstein, Potts, & Mattox, 1985) was developed to assess
the impact of infertility on the domains of self-esteem, blame/guilt, and sexuality. The IFQ is a
21-item self-report measure in which subjects are asked to indicate their level of agreement on a
5-point Likert scale. The test was found to have adequate reliability and validity (Bernstein et al.,
1985). Developers of the scale suggest its use, in conjunction with a standard measure of psychological
distress, by nurse specialists in order to assess the need for counseling.
In summary, a standard battery for infertility patients should include a brief measure of anxiety
(such as the shortened form of the STAI), a measure of depression (such as the BDI), a brief mea-
sure of relationship satisfaction (such as the DAS-7), and at least one measure of infertility-specific
distress (such as the FAS). Because of the ease of administering and interpreting these measures, the
battery could be administered by nurses and office clerks as well as by mental health professionals
MHPs. The battery should be given to all incoming infertility patients upon intake in order to assess
Infertility • 227
the psychological status of each patient, to begin prevention protocols, and to develop treatment
targets. The battery should be readministered at monthly intervals to monitor changes in patient
status on these common psychological sequelae of infertility. Any changes in patient status should
be shared with both the physician and the MHP. Finally, the battery should be administered on ter-
mination of treatment to assess the effectiveness of any psychosocial treatment administered and to
make referrals for additional treatment if necessary.
When special situations or populations are involved, such as in third-party reproduction, care
should be taken to tailor the assessment. For example, in the case of donor insemination (DI),
Zoldbrod and Covington (1999) suggest that practitioners assess the couple’s feelings about male-
factor infertility and the meanings that each partner assigns to it, the couple’s readiness for DI,
and the indications and contraindications for DI. Greenfeld (1999) outlines issues to consider in
the assessment of patients considering the use of oocyte donation (OD), including grieving the loss
of a potential child that shares a genetic relationship with both parents. Clinicians working with
potential gamete donors should refer to Applegarth and Kingsberg (1999), who outline issues to
include in a structured clinical interview for potential donors. If clinicians wish to screen out major
psychopathology, they should employ standardized measures of psychopathology, such as the
Minnesota Multiphasic Personality Inventory (MMPI) in addition to clinical interviews.
Existing Treatments for Infertility
Medical Options
It is crucial that mental health professionals working in the field of infertility have a thorough
understanding of the medical procedures involved in infertility treatment. Knowledge of such med-
ical treatments for infertility will not only increase the credibility of psychological involvement
in the treatment of infertility, but will also facilitate communication with both clients and
medical personnel involved in treatment. Descriptions of medical options for infertility treatment
can be found in existing literature (Keye, 1999; McDaniel, Hepworth, & Doherty, 1992; Meyers
et al., 1995; Williams et al., 1992).
Adjunct Psychological Interventions

Given the psychological problems that can be co-morbid with infertility, such as stress, depression,
and marital difficulties, a number of psychological interventions have been developed and
implemented with infertile individuals who are distressed. Despite the use of these interventions,
there is a paucity of research examining their effectiveness (Domar, Seibel, & Benson, 1990; Domar,
Zuttermeister, Seibel, & Benson, 1992b). Typical goals of existing interventions include conducting
a thorough assessment, treating any psychological problems uncovered during the assessment,
providing psychoeducation as to the workings of the reproductive system and assisted reproduc-
tion, giving the couple an estimate of their fertility potential, providing emotional support, and
counseling the couple as to the various options available to have children (Klock, 1999).
Psychoeducation. Most clinicians agree that any form of psychological intervention should include
a component of psychoeducation, where couples are taught about the reproductive system, assisted
reproduction techniques, and the psychological problems that can be concomitant with infertility
(e.g., Daniluk, 1991). Clinicians and researchers also agree that it is important to help individuals
by normalizing their strong reactions to infertility (Mahlstedt et al., 1987), especially so that they
feel they are not “crazy” for feeling the way they do (McNaughton-Cassill et al., 2000).
Support Groups. Many infertile couples turn to support groups during times of infertility-related
distress. These support groups can serve a normalizing function for couples, where they learn that
they are not the only ones experiencing the psychological sequelae of infertility (McNaughton-
Cassill et al., 2000). RESOLVE is a national support and informational network for individuals with
infertility. Developed by Barbara Eck Menning, the organization has chapters that offer support
groups in many major cities. Support groups may primarily function to provide solace and com-
fort, but are often also used as a venue to teach cognitive behavioral techniques such as relaxation
skills, stress management skills, and other coping skills.
Cognitive Behavior Therapies. The majority of therapies conducted with infertility clients utilize a
group format and employ some form of cognitive behavior therapy (CBT) as the intervention.
Thus, CBT is commonly applied to problems with stress management, relaxation, depression,
coping skills, and grief counseling. Myers and Wark (1996) argue that a cognitive behavioral
approach is the most appropriate intervention to use with infertile couples for a variety of reasons.
First, they argue that the cognitive behavioral approach has established empirical support for a vast
array of couples issues (e.g., Baucom & Hoffman, 1986; Gurman, Kniskern, & Pinsof, 1986; Jacobson,
Schmaling, & Holtzworth-Munroe, 1987). Second, the cognitive behavioral approach has instituted
techniques for awareness and modification of automatic thoughts (Beck, Rush, Shaw, & Emery,
1979) and could address such dysfunctional thoughts in infertile couples. Third, the cognitive
behavioral approach also makes use of behavior modification strategies that can be used with infer-
tile couples to overcome avoidance behavior and to alleviate stress and depression. Fourth, the
cognitive behavioral approach has been established as an effective way to help couples improve
their communication skills, and could help infertile couples express their emotions and needs.
Finally, the sexual difficulties experienced by infertile couples could be addressed through validated
cognitive behavioral techniques to treat sexual dysfunctions (Masters & Johnson, 1966, 1970).
As such, cognitive behavioral therapies applied to the infertile population have received empirical
support (Tuschen-Caffier et al., 1999).
McNaughton-Cassill et al. (2000) have developed and investigated the effectiveness of a brief
stress management support group for couples in IVF treatment. The group employed a cognitive
behavioral format, in which cognitions about fertility were identified and challenged, links between
irrational thoughts and expectations and emotional distress were explored, and couples were taught
techniques for reframing attributions and generating alternative thoughts and solutions for their
problems. Data indicated that overall, couples valued the social support offered in the group and
felt the group helped them deal with the stress of IVF treatment.
Domar and colleagues (Domar et al., 1990; 1992b; Domar, Friedman, & Zuttermeister, 1999)
have developed and tested the Mind/Body Program for the treatment of stress in infertile couples.
These researchers reasoned that it might be useful to apply the relaxation response to the infertile
population since it has been established that regular use of the relaxation response leads to
decreased tension and stress, and there are data to indicate a relationship between stress and fertil-
ity. Researchers tested the hypotheses that infertile women using the relaxation response would
have decreased levels of stress and increased rates of conception after completing their 10-week
course by collecting pre- and posttreatment measures of stress, anxiety, mood, and anger. The
Mind/Body Program for Infertility consists of teaching patients how to elicit the relaxation
response, practicing relaxation exercises in a group, and a weekly lecture on a variety of cognitive
behavioral topics (e.g., psychoeducation about the relationship between stress and the reproductive
system, explanation of the physiology of stress, diaphragmatic breathing, cognitive restructuring
and affirmations, nutrition, mindfulness, and emotions). Results indicated dramatic changes from
pre- to postintervention. There were significant decreases in measures of depression, tension, and
Infertility • 229
anxiety. Significant increases occurred in measures of mood and activity, and there was a trend to
increase the healthy expression of anger. There were also dramatic improvements in subjective
reports of feelings of control, security, well-being, and self-esteem. Furthermore, 34% of the partici-
pants conceived within 6 months of completing the program. Researchers concluded that regular
elicitation of the relaxation response could increase the potential for conception in couples with infer-
tility (Domar et al., 1990). Similar results were found on replication (Domar et al., 1992b; 1999).
Given the effectiveness of the above cognitive behavioral techniques applied to the infertile
population, clinicians should also consider using other standard and empirically supported
cognitive behavioral therapies, such as those recommended by the Division 12 Task Force on
Psychological Interventions (Task Force on Promotion and Dissemination of Psychological Proce-
dures, 1995; Woody & Sanderson, 1998), with clients struggling with stress, depression, and marital
difficulties associated with infertility. Empirically supported treatments for relaxation training
include Progressive Relaxation Training by Bernstein and Borkovec (1973; see also Carlson &
Bernstein, 1995). Linehan’s (1993a, 1993b) Dialectical Behavior Therapy has also received empirical
support for teaching coping skills to reduce distress.
Cognitive behavioral therapy can also be applied to alleviate the symptoms of depression
commonly associated with infertility. Empirically supported cognitive behavioral therapies for
depression (Beck, 1995; Beck et al., 1979; Burns, 1980; Lewinsohn, Antonuccio, Breckenridge, &
Teri, 1984; Lewinsohn, Munoz, Youngren, & Zeiss, 1992) can help infertility clients through identi-
fication of dysfunctional thoughts, relearning/reframing/reattribution and modification of these
faulty cognitions, and teaching effective behavioral skills, such as activity schedules, exposure, and
behavioral rehearsal of skills aimed at improving mood.
Hunt and Monach (1997) have adapted principles of CBT to the cognitive distortions commonly
held by infertility clients. They define and identify the following examples of such thinking with
respect to male-factor infertility. First, overgeneralization is defined as taking one event or aspect of
an event and drawing a general conclusion from it, such as thinking, “If I cannot father a child, I am
not a man at all” (p. 192). Second, selective abstraction is taking one aspect of a situation and defining
the entire situation based on that detail, as in thinking, “I cannot have a proper sexual relationship
if my spermatozoa are infertile” (p. 192). Third, magnification and minimization are defined as
exaggerating the importance of negative aspects of a situation or inappropriately shrinking the
positive aspects of the situation, respectively. Examples of magnification and minimization are,
“My wife cannot enjoy sex with me if I am not fertile,” and “My wife only says she loves me still
because she pities me,” respectively (pp. 192–193). Fourth, personalization involves seeing oneself
as the cause of some negative external event whereas there was actually no personal responsibility.
An example of personalization with respect to infertility is thinking, “Now the doctor says that she
is not ovulating, maybe this is because of my sperm problems” (p. 193). Finally, Hunt and Monach
(1997) define arbitrary inference as jumping to a conclusion without adequate evidence, such as in
thinking, “If I had had fewer sexual partners I would still be fertile” (p. 193). In the CBT tradition,
clients should be taught how to maintain records of automatic thoughts, which include recording
the situation, the feelings experienced, the automatic thought, a challenge to the automatic
thought, and the subsequent outcome (Hunt & Monach, 1997). They should also be taught the
importance of engaging in pleasant activities, especially those that include sources of satisfaction
alternative to fertility (Myers & Wark, 1996).
Given that infertility is commonly associated with relationship difficulties, infertile couples
suffering from marital dissatisfaction should be offered an empirically supported cognitive behav-
ioral therapy for couples (e.g., Gottman & Rushe, 1995; Jacobson & Margolin, 1979). In the con-
text of such therapies, couples should learn how to identify and challenge cognitive distortions
about infertility and marriage, learn the relationship between behavior exchange and relationship
satisfaction, be encouraged to engage in mutually pleasurable activities, be encouraged to seek out

sources of satisfaction other than childrearing (Callan & Hennessey, 1989), learn communication
skills in order to express and understand each other’s feelings about infertility, learn problem-
solving skills aimed at helping the couple decide on treatment issues and deal with insensitive social
comments, be warned about dangerous interaction patterns of communication such as demand-
withdraw (e.g., Christensen & Heavey, 1990), and learn the importance of having sexual intercourse
during the most fertile times of the cycle.
Adapting Empirically Supported Treatments to the Medical Setting. Robinson (chapter 2, this
volume) has made a number of suggestions for successfully adapting evidence-based treatments
into the medical setting. Consistent with her suggestion to reduce treatment length and intensity of
treatment, it is suggested that mental health professionals working with infertility patients distil the
essence of the above empirically supported treatments into a number of condensed treatment
modules. For example, a module on stress reduction and relaxation could be drawn from the
empirically supported work of McNaughton-Cassill et al. (2000), Domar and colleagues (Domar
et al., 1990, 1992b, 1999), Bernstein and Borkovec (1973), and Linehan (1993a, 1993b). This mod-
ule could target how to apply cognitive behavioral relaxation and stress reduction techniques to the
stress associated with infertility. Similarly, another module for combating the depression commonly
associated with infertility could be developed based on the empirically supported work of Beck and
colleagues (Beck, 1995; Beck et al., 1979), Burns (1980), Lewinsohn and colleagues (1984, 1992),
and Hunt and Monach (1997). This module could target how cognitive distortions associated with
infertility affect mood, and how patients can modify their cognitions and use effective behavioral
skills in order to enhance their mood. The empirically supported cognitive behavioral work of
Gottman and Rushe (1995) and Jacobson et al. (1979) in relationship satisfaction could be used to
develop a third module on the relationship problems commonly associated with infertility. This
module could target combating cognitive distortions associated with infertility and marriage as well
as relationship skills needed to solve marital difficulties resulting from infertility. A fourth module
could address assertiveness skills based on the empirically supported work of Gambril (1995). In
this module, infertility patients could learn cognitive behavioral skills to deal with intrusive friends
and family members and with the social stigmas associated with being infertile in a fertile world.
Consistent with Robinson’s (chapter 2, this volume) suggestion that mental health professionals
working in medicine adopt a “patient education, self-management model,” a psychoeducational
module aimed at explaining and normalizing the psychological sequelae of infertility, as well as a
brief introduction to self-management skills, should be included in the series of modules offered to
patients with infertility. The module should outline the causes, diagnoses, and various treatments
for infertility. It should also cover options for family building, including the psychosocial issues
associated with each. This psychoeducational module, along with referrals to appropriate self-help
books and infertility support groups such as RESOLVE, should be part of a standard prevention
protocol instituted for each patient in the practice.
All modules should be 2–12 weeks in duration and should meet for 30 to 60 minutes weekly in a
group format. Groups should be open, allowing in new patients at any time. Consistent with the
Primary Behavioral Health Care Model (Robinson, chapter 2, this volume) group sessions should
be conducted in an office nested in the infertility clinic. This approach has the likelihood of further
integrating medical and psychosocial care, including the potential benefits of an integrated care
program (e.g., Katon et al., 1992; Robinson & Strosahl, 2000). In the context of a stepped-care
model, patients should first be referred to these groups then further referred to individual therapy if
their symptoms persist or worsen.
Infertility • 231
Ideally, patients entering medical treatment for infertility would be given a brief battery of
psychological measures aimed at assessing the level of distress associated with their fertility
problems. Consistent with the population care model used in medicine, all infertility patients,
regardless of their scores on the measures, would be offered the psychoeducational and self-
management skills module described above. This model of service delivery aims to improve the
health of the entire community of infertile patients by preventing psychosocial distress associated
with infertility, identifying and treating distress early on, and supporting healthy lifestyles in order
to maximize chances of pregnancy and live birth (Robinson, chapter 2, this volume). However,
patients with elevated scores on measures of psychosocial distress would be referred to modules
appropriate to their type of distress. All patients should be given a brief battery of psychosocial
questionnaires on a monthly basis to monitor their progress on the psychological sequelae of infer-
tility. Patients with improved scores can then titrate their treatment by decreasing the number of
sessions they attend and eventually terminating sessions. These patients should schedule follow-up
and booster sessions as needed. Patients with scores indicating increased distress should either
attend group sessions more often or more consistently, or should be offered individual sessions in
the context of a stepped-care model. Of course, any change in the patient’s psychosocial status
should be communicated with physicians immediately.
Treatment Compliance. Little empirical data exist with respect to the treatment compliance of
patients seeking medical treatment for infertility. Given the highly desirable outcome of having
their own biological child, the tremendous financial investment in the treatment, and patient’s
willingness to undergo painful and invasive fertility procedures for years, it can be assumed that
infertility patients are highly motivated for treatment and tend to be compliant with treatment.
One study investigating the reasons for termination of fertility treatment did not cite problems with
compliance as a common reason to discontinue treatment (Hofmann, Jeschke, & Jeschke, 1985).
In a study analyzing the motivation and compliance of andrology patients, researchers concluded
that patients who desired a child demonstrated higher levels of cooperation and compliance
(Pusch, 1985).
Compliance with psychosocial treatments for the psychological sequelae of infertility has also
received little empirical analysis. Most treatment-outcome studies in this field did not cite attrition
rates or explicitly make any references to problems with treatment compliance. However, Domar
et al. (1992b) reported that only 5–10% of self-referred patients evaluated for group therapy did
not join the group, and many did not join for practical reasons (e.g., scheduling conflicts, geo-
graphical relocation, conception before treatment). Although it is likely that infertility patients will be
generally compliant with psychosocial treatments for the psychological sequelae of infertility, it is
important to monitor and address compliance, especially upon initial referral and if patients are
concerned with the stigmas of infertility or psychotherapy. In order to maximize compliance with
psychosocial treatment, it is essential to integrate it with medical treatment for infertility. All
patients who enter treatment should be given a full psychosocial assessment and attend a psychoed-
ucational treatment module on the psychological sequelae of infertility. Patients who demonstrate
elevated scores on specific psychological symptoms should be referred to other appropriate treat-
ment modules. Physicians and MHPs should be in close communication regarding any changes in
patient status, and the relationships between mental health, physical health, and fertility should be
explained to all patients.
Long-Term Management. Because successful medical treatment for infertility can take many years
and because some couples are never able to achieve live birth through medically assisted reproduc-
tion despite years of trying, it is important to consider long-term management of infertility. Within
the context of a stepped-care model, patients demonstrating psychological sequelae of infertility

should be initially treated in a group-therapy format. If their symptoms persist or worsen, these
patients should be referred to individual therapists for treatment of their psychological problems
associated with infertility. However, if their symptoms improve, patients seeking continued psycho-
social treatment could be referred to community support groups for infertility, such as those
provided by RESOLVE.
Patients with prolonged medical treatment failures should be advised to consider the option of
stopping medical treatment for infertility. Many patients are so hopeful to have a biologically
related child that they have not even considered alternatives, even in the face of continued
treatment failures (Stephenson, 1987). MHPs can gently help such infertility patients to gradually
consider and get used to the idea that they may not have biological children of their own. However,
MHPs should emphasize to patients that they still have choices, even though those choices may not
include biologically related children. MHPs can help infertility patients to explore alternatives such
as adoption, artificial insemination by donor, surrogate motherhood, and child-free living. The
pros and cons of each alternative, as well as couple’s reactions to these alternatives, should be pro-
cessed. Issues of couple disagreement over alternatives should be addressed. In addition, it is
important to help patients grieve the loss of the potential for having biologically related children.
Collaboration Between Mental Health Professionals and Infertility Physicians. It is important

to note that the above therapies received empirical support when they were delivered by competent
master’s- or doctoral-level psychotherapists. Thus, treatment for the psychological sequelae of
infertility should be delivered by licensed psychologists or psychiatrists, or by therapists being
supervised by such licensed professionals. These MHPs should collaborate with the physicians
whose clients they share in order to ensure the most integrated and continuous care. Collaboration
between MHPs and physicians can be maximized in the following ways. First, the MHP should
emphasize to the physicians the potential benefits of collaboration. The pressures faced by infertility
specialists are similar to those faced by primary care doctors with respect to heavy patient loads,
being confronted with the psychosocial problems of their patients, having limited time with their
patients, and dealing with treatment compliance issues. MHPs should describe how they could
reduce the physician’s treatment load by splitting the responsibilities such that MHPs address the
patient’s psychosocial issues and the physicians address the medical issues. Consistent with the
Primary Behavioral Health Model, MHPs would not take charge of the patient’s care but would
manage the patient within the structure of the integrated health-care team (Robinson, chapter 2,
this volume). Given the possible connection between stress and infertility, it should also be empha-
sized that improved psychological well-being may also increase the physician’s conception rates.
MHPs should also explain how they can use psychological principles (such as motivational
interviewing) to improve patient compliance with medical regimens. Second, on a broader level,
MHPs can maximize collaboration with physicians by publishing in medically oriented infertility
journals. Such publications could educate physicians about the psychological sequelae associated
with infertility, the relationship between stress and infertility, psychosocial treatments for the
emotional sequelae of infertility, and the importance of collaboration with MHPs. Third, these
topics could also be addressed in workshop format. Such workshops could be presented by MHPs
at national conferences for reproductive endocrinologists and obstetricians/gynecologists. Fourth,
MHPs could benefit by forming a professional alliance with national organizations for reproductive
endocrinologists and obstetricians/gynecologists (e.g., American Fertility Society, American
College of OB/GYN). Finally, on an individual and local basis, MHPs can maximize collaboration
with physicians by keeping open the lines of communication regarding their shared patients. The
more physicians are given updates regarding the patients they refer to MHPs, the more likely they
Infertility • 233
will be to reciprocate with vital medical information that may affect psychological functioning, act
as a team with MHPs in providing the most seamless patient care and maximizing treatment
outcomes, and continue referring patients with mental health concerns. Ideally, all members of the
integrated health care team, including MHPs, nurses, and physicians, would meet weekly to discuss
the status of each patient and to provide the most seamless and integrated patient care.
Prior to starting psychotherapy, all patients should have a clear understanding of the collabora-
tive nature of the relationship between their MHP and their fertility specialist. Patients should
know that their therapist and their physician will be discussing their case in order to provide the
most integrated care and to maximize the chances of live births for the patients. However, this
open sharing of information between therapists and physicians may impede some patients from
seeking mental health services or from being forthcoming with psychological difficulties if patients
fear the doctors will deem then “bad patients” or “bad parents” and discontinue treatment for
infertility. Because patients must rely on their infertility specialist to help them achieve their dream
of having a baby, they may conceal their true feelings of fear, anxiety, sadness, anger, disappoint-
ment, and grief. They may also conceal marital difficulties for fear that their doctor may see them as
potentially poor parents. If patients know that their therapist will share information with their
physician, they may also avoid disclosing their emotional difficulties to their mental health specialist.
Validating and normalizing their reactions to infertility and medical treatment can assuage patient’s
fears. It is also crucial for therapists to share with patients the parameters around confidentiality
and the types of information that can be shared with physicians.
It is suggested that physicians not have access to patient’s weekly session notes, but that a
monthly progress checklist noting patient attendance in sessions, changes in scores on psychologi-
cal measures of distress, and a listing of general patient issues being addressed be used. For exam-
ple, therapists can share with physicians that their patients attended three group sessions this
month in which the following topics were addressed: relaxation techniques, increasing pleasant
events, and communication skills. Scores on psychological measures could be relayed in graph
format, charting changes in scores across time. MHPs should be sure to include brief remarks on
the clinical meanings and significance of the scores. Therapists should also be sure to convey infor-
mation about techniques used to increase patient compliance with medical regimens. As noted
above, although motivation for treatment and patient compliance tend to be very high in this pop-
ulation, one area of difficulty in compliance is getting couples to abstain from sexual intercourse
during certain nonfertile parts of the menstrual cycle and to engage in intercourse during the fertile
times of the cycle. Therapists should note to physicians that they are addressing this problem using
behavioral techniques.
Potential Medical Cost Offset

If there is indeed a connection between stress and fertility, and if a reduction of stress does contribute
to increased fertility rates, as has been suggested in the literature (e.g., Harrison, O’Moore, &
O’Moore, 1986a; 1986b; McGrady, 1984; Moghissi & Wallach, 1983; O’Moore, O’Moore, Harrison,
Murphy, & Carruthers, 1983; Pook, Rohrle, & Krause, 1999), then it may be hypothesized that a
reduction of stress and other psychological problems co-morbid with infertility has the potential to
enhance the effectiveness of medical infertility treatment. Couples who are less distressed, using
effective coping skills, and communicating well may be more likely to adhere to infertility
treatment; cope well with the stress of treatment; stay in treatment long enough to conceive
(Domar, 1997); have regular sexual intercourse, especially during times of greatest possible fertility;
and therefore maximize their chances of conceiving.
Although there is a logically compelling argument for the addition of behavioral health care to
the standard medical treatment of infertility, there are as yet no data regarding the potential medical
cost offset of such an addition. Empirical analysis is needed in order to assess the effects of adding
psychosocial treatments for patients suffering from the psychological sequelae of infertility. Such
analysis should consider the direct costs, such as therapist fees (approximately $120–150 per hour
of group sessions led by a Ph.D.-level therapist and $50–75 for a master’s-level therapist or social
worker). It is also crucial to consider potential indirect costs for infertility patients, such as reduced
productivity and days off work due to psychosocial symptoms related to infertility, and the threat to
the reproduction and continuity of the patient’s family. If stress does diminish fertility, then
additional potential indirect costs include decreased effectiveness (rate of successful pregnancies)
and efficiency (number of cycles required to achieve successful pregnancy) of medical fertility
treatments, which may then lead to increased medical costs and cyclical deterioration of psycholog-
ical functioning.
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Chapter 12
The Integration of Psychosocial Interventions
Into the Oncology Practice
ADRIENNE H. KOVACS AND ARTHUR C. HOUTS
More than one third of North Americans will be diagnosed with cancer during their lifetimes
(Greenlee, Hill-Harmon, Murray, & Thun, 2001; National Cancer Institute of Canada, 2001).
Cancer is the second-leading cause of death in the United States (Greenlee et al., 2001). Cancer is
not a single disease; rather, it is a group of related diseases that involve the uncontrolled growth and
spread of abnormal cells. Tumors that are formed from this atypical cell division may be benign or
malignant, and it is the malignant tumors that are diagnosed as cancer. Not all cancers result in the
formation of tumors, however. Cancer cells may also exist in the blood and blood-forming organs
(bone marrow, lymphatic system, and spleen). Among men, the most common diagnoses are
prostate, lung and bronchus, and colorectal cancers, whereas among women, breast, colorectal, and
lung and bronchus cancers are most frequently diagnosed (Greenlee et al., 2001). In a process
known as metastasis, cells from malignant tumors may invade other tissues and organs by breaking
away from the original tumor site and entering the bloodstream or lymphatic system. As cancer in
this new location still consists of abnormal cells from the original site, it retains the original name.
For example, if breast cancer spreads to the brain, this is referred to as metastatic breast cancer
(i.e., not brain cancer). In addition to description referring to the original site of the abnormal cell
activity, cancers are “staged” according to the extent of the disease, with higher stages indicative of
disease that is more advanced and has spread from the original site. Within the tumor node
metastasis (TNM) staging system, tumors are assigned a stage of I, II, III, or IV; within the summary
staging system, cancers are labeled as in situ, local, regional, or distant.
Treatment options include surgery, radiation, chemotherapy, hormonal therapy, and immuno-
therapy. In addition to the surgical removal of the cancerous tumor, surrounding tissue and lymph
nodes may also be removed. Surgery is often accompanied by radiotherapy, the use of high-energy
particles or waves to destroy cancer cells at a specific site. Radiation therapy may be used before
surgery for the purpose of shrinking the tumor (neoadjuvant surgery) or afterward in order to
destroy any remaining cancer cells (adjuvant therapy). Radiotherapy can also be used without
surgery, particularly if surgery is not possible, and it may also be recommended for pain relief. In
contrast to the localized effects of surgery and radiation therapy, chemotherapy, hormone therapy,
237
and immunotherapy are referred to as systemic treatments because they do not target one specific
location. Chemotherapy, the administration of drugs to kill cancer cells, may be the only treatment,
may be used in conjunction with radiotherapy, and may precede or follow surgery in a neoadjuvant
or adjuvant fashion. Chemotherapy drugs, which can be administered orally or injected, travel
through the bloodstream and reach all cells, both cancerous and healthy. Side effects often occur as
a result of the drugs’ impact on healthy cells, including cells that fight infection, carry oxygen
throughout the body, or line the digestive tract. The side effects associated with these five treat-
ments may be short term (e.g., fatigue, hair loss, nausea, and vomiting) or long term and even
permanent (e.g., loss of fertility). Hormone therapy refers to the administration of drugs that inter-
fere with hormone activity or the surgical removal of hormone-producing glands. This treatment
targets cancers that involve hormones in the proliferation of abnormal cells (e.g., ovarian and
testicular cancer). Immunotherapy, also known as biological therapy, enhances the body’s own
immune system to fight against treatment side effects or the cancer itself. For example, patients may
undergo bone marrow transplantation or stem cell transplantation in order to replace those cells
damaged by chemotherapy or radiotherapy with healthy cells. Each of these five treatment options
may be used alone or in combination with other treatments. The overall treatment approach is
determined by several factors including the location and stage of cancer and whether the disease has
spread throughout the body. Cancer is a physical disease, but as with many other diseases, cancer
affects the broader overall functioning of patients.
Biopsychosocial Aspects of Cancer

This chapter presents a biopsychosocial conceptualization of the cancer experience. In addition to
changes at the cellular level, cancer typically has broader effects on an individual’s physical, psycho-
logical, and interpersonal functioning.
The impact of cancer on one’s body is not limited to specific cancerous cells. The disease and its
treatment can affect physical well-being in a variety of ways. Fatigue is one of the most commonly
reported symptoms. Estimates of Canadian and American cancer patients who experience fatigue
range from 70–78% (Ashbury, Findlay, Reynolds, & McKerracher, 1998; Smets, Garssen, Schuster-
Uitterhoeve, & de Haes, 1993). Patients undergoing chemotherapy or radiation therapy typically
report greater levels of fatigue than cancer-free individuals (Irvine, Vincent, Graydon, Bubela, &
Thompson, 1994; Jacobsen et al., 1999). In addition to increased reports of fatigue, almost half
of all cancer patients experience sleep disturbance (Beszterczey & Lipowski, 1977). Regular sleep
patterns are particularly susceptible to disruption during hospitalization or when a patient is
experiencing pain attributed to treatment or the disease itself. Individuals with cancer may experi-
ence pain at any stage of the disease process, and this pain may be persistent (Greenwald, Bonica, &
Bergner, 1987). Daut and Cleeland (1982) observed that, depending on the location and stage of
cancer, the prevalence of patient-reported pain ranged from 0% to 75%. It was highest among
cancer patients with metastatic disease. Unfortunately, research suggests that unmet analgesic needs
and situations in which doctors’ estimates of patient pain are less than patient reports are rather
common (Peteet, Tay, Cohen, & MacIntyre, 1986; Zhukovsky, Gorowski, Hausdorff, Napolitano, &
Lesser, 1995). Among individuals with cancer, it is clear that the majority will experience at least
some degree of pain, fatigue, and/or sleep disturbance.
With regard to the psychological changes that may accompany cancer diagnoses and treatments,
the experiences are likely to vary among individuals. The impact of cancer on mood and symptoms
of depression and anxiety is addressed in the next section. There are, however, other ways in which
cancer can affect an individual’s emotional or cognitive functioning. Individuals with cancer may
strive to make meaning of this event or to reprioritize aspects of their lives (Curbow, Somerfield,
The Integration of Psychosocial Interventions Into the Oncology Practice • 239
Baker, Wingard, & Legro, 1993; Taylor, 1983). They may experience a change in self-identity when
faced with changes in appearance, such as the loss of a breast, postsurgical scarring, or hair loss due
to chemotherapy. Depending on the size and location of the tumor, individuals with cancer of the
brain may undergo changes in personality or memory. At the behavioral level, whether by necessity
or choice, cancer patients commonly experience at least a temporary change in their daily activities.
For example, daily radiotherapy appointments may replace morning routines for several weeks.
Individuals may also decide to change their diet, exercise patterns, or tobacco and alcohol con-
sumption after receiving a cancer diagnosis. In summary, cancer patients typically experience psy-
chological changes across affective, cognitive, and behavioral domains.
The various physical and psychological changes associated with cancer diagnoses and treat-
ments do not affect only the patient. They may also affect family members, friends, and coworkers
as well as patients’ relationships with these individuals. Within marriages, communication diffi-
culties and role shifts may occur (Lichtman, Taylor, & Wood, 1988). It has also been estimated that
20–90% of cancer patients experience sexual dysfunction or dissatisfaction, with higher rates of
sexual difficulties reported among gynecologic patients (Andersen, 1985). Such changes in com-
munication and sexual functioning affect both patients and their partners. In addition, cancer
patients may experience rather significant changes in their social environments. For example, they
may begin spending increased time interacting with members of their health-care team and other
cancer patients, and spend less time with coworkers or casual friends. Friends and family members,
who may themselves be attempting to find meaning in their loved one’s cancer, may alter the way
in which they interact with the patient. They may withdraw due to personal discomfort or fear
regarding the situation. Alternatively, they may begin spending increased amounts of quality time
with the cancer patient. There are also situations in which social interactions may be extremely
affected due to the cancer experience. In order to avoid infections, individuals who have recently
undergone bone marrow transplantation, for example, have extremely limited social contact, even
with close family members.
Although cancer diagnoses and treatments are often associated with biological, psychological, or
social changes, these three domains are not easily separated. For example, it is rarely possible to sep-
arate physical effects from the psychological or social changes that accompany cancer. Fatigue, one of
the most commonly reported symptoms among cancer patients, is associated with greater levels of
anxiety and depression and poorer physical and mental health (Hann, Jacobsen, Martin, Azzarello,
& Greenberg, 1998). Spiegel, Sands, and Koopman (1994) have found that cancer patients who
reported higher levels of pain were more likely to be given a clinical diagnosis of depression. This
was observed despite a history of more frequent episodes of major depression among individuals
who reported lower pain. In addition, Daut and Cleeland (1982) have reported that cancer patients
with the highest reports of physical pain were more likely to report that this pain interfered with
their usual activity level and enjoyment of life. As a general strategy, it is inappropriate to explore
any single change associated with the cancer experience in isolation of other changes.
Assessment Strategies
Within this biopsychosocial framework, it is evident that the majority of individuals will experience
at least some degree of change when coping with a cancer diagnosis and its subsequent treatment.
Mental health professionals have moved from the traditional mental health field into oncology
settings and offered interventions in order to improve patients’ cancer experiences. It would be very
appealing if there were an accurate method of identifying a select group of cancer patients who are
in most need of intervention, are most likely to participate in interventions, and would realize the
most benefits from participation. In addition to the attempt to identify the need for treatment,
there are two other reasons why mental health professionals should be aware of methods used in
the assessment of cancer patients. First, consistent with the scientist-practitioner model, even
individuals who do not plan to publish their results should assess the impact of their interventions.
Second, issues of quality assurance demand the systematic evaluation of treatment effectiveness.
In order to survive in the oncology setting, mental health professionals must be prepared to “prove”
their worthiness to physicians and managed-care organizations. The clear interpretation of results
obtained from standardized assessment instruments should aid in this process. Two approaches for
the systematic assessment of cancer patients for the purposes of recruitment into psycho-oncology
interventions and the systematic evaluation of these interventions are presented. Finally, a third
approach that could be applied to all cancer patients is considered.
Traditional Mental Health Assessment

Many researchers have offered support for the psychological screening of cancer patients (Greer,
1989; McDaniel, Musselman, & Nemeroff, 1997; Payne, Hoffman, Theodoulou, Dosik, & Massie,
1999; Zabora, Smith-Wilson, Fetting, & Enterline, 1990). This approach is based upon the notion
that such screening will be an efficient way of determining who is in most need of psychological
intervention. Some researchers limit participation in psychosocial interventions to individuals who
report high levels of psychological distress (Ford et al., 1990; Greer et al., 1992; Telch & Telch, 1986;
Worden & Weisman, 1984).
Others advocate the position that, due to difficulties associated with the accurate identification
of depressed medical patients through current screening processes and the paucity of evidence link-
ing screening with improved outcomes, there is little evidence in favor of psychological screening
(Campbell, 1987; Coyne, Thompson, Palmer, Kagee, & Maunsell, 2000; U.S. Preventive Services
Task Force, 1996). In addition to a lack of evidence in support of blanket screening, possible risks
associated with this practice have been proposed. The domain of somatic symptoms included in
many standardized mental health instruments may lead to confusion. Health-care team members
might neglect either the physical causes or psychological causes of high-scorers’ somatic complaints
(Tope, Ahles, & Silberfarb, 1993). Other potential risks include the inaccurate labeling of screened
patients with mental health diagnoses, the withdrawal of attention from disorders with effective
screening methods, and damage to the patient-doctor relationship (Campbell, 1987).
As the debate regarding psychological screening is not likely to soon dissipate, it is helpful to
review the research literature on the psychological functioning of cancer patients. After adminis-
tering self-report measures of depression or anxiety, many research teams have concluded that indi-
viduals with cancer, as opposed to the general population, are more likely to report symptomatology
in the clinical range (Epping-Jordan et al., 1999; Glinder & Compas, 1999; Pinder et al., 1993;
Watson et al., 1991). There is significant variation in terms of the published rates of psychological
symptomatology among cancer patients; the prevalence rates of depression and anxiety have ranged
from 0–50% and from 0.9–49%, respectively (McDaniel, Musselman, Porter, Reed, & Nemeroff,
1995; Van’t Spijker, Trijsburg, & Duivenvoorden, 1997).
The majority of research investigating the psychological status of cancer patients has relied on
self-report measures. There are many readily available measures of mood and symptoms of depres-
sion and anxiety that have often been used for this purpose. This list includes the Beck Depres-
sion Inventory (BDI; Beck & Beck, 1972), the Hospital Anxiety and Depression Scale (HADS;
Zigmond & Snaith, 1983), and the Profile of Mood States (POMS; McNair, Lorr, & Droppleman,
1971). However, after conducting clinical interviews with 215 cancer patients undergoing medical
treatment, Derogatis et al. (1983) assigned a DSM-III (Diagnostic and Statistical Manual of Mental
Disorders) major affective disorder diagnosis to only 6% of the sample. In similar fashion, Lansky
and colleagues (1985) administered clinical interviews to women with a history of cancer and
found that 5.3% of the women were experiencing clinical levels of depression. Among this group of
505 women, in which the time since diagnosis ranged from 2 weeks to 23 years, time since diagnosis
did not differentiate between the depressed and nondepressed women. Within the cancer popula-
tion, research suggests that only one third to one half of cancer patients who report significant dis-
tress on self-report measures will receive a clinical diagnosis after an interview has been conducted
(Kathol, Mutgi, Williams, Clamon, & Noyes, 1990; Payne et al., 1999). Therefore, there is quite a
contrast between the self-report of depressive symptoms and diagnoses obtained through formal
clinical interviews.
There is other research to suggest that cancer patients are quite similar to physically healthy
individuals in terms of their psychological status. In one study, cancer patients were found to report
less mood disturbance than both college students and outpatient psychotherapy clients (Cella et al.,
1989). In another study, the mental health of medical patients, including those with cancer, was
observed to be similar to the mental health of the general population and better than individuals
undergoing treatment for depression (Cassileth et al., 1984). In their meta-analysis, Van’t Spijker
et al. (1997) found that cancer patients did not report more symptoms of anxiety or distress than
nonpatients. When the analysis was limited to studies published after 1987, cancer patients did not
report more symptoms of depression than their healthier counterparts. Due to equivocal research
findings using self-report measures, it would appear to be inaccurate and inappropriate to presume
that cancer patients commonly experience significant levels of psychological distress.
Therefore, the administration of self-report measures of psychosocial distress does not appear to
be a particularly effective solution for those wishing to identify cancer patients for whom an inter-
vention would be most appropriate. Mental health professionals working in the oncology setting
must also not forget that they are working with cancer patients rather than typical mental health
patients. Cancer patients may not welcome the routine assessment of their psychological status
during visits with their oncologists. This is not to suggest, however, that psychological disturbance
is absent in the cancer population. It is likely that a continuum of psychological health exists; some
cancer patients will meet diagnostic criteria for a psychological disorder, others will experience
increased distress without reaching clinical levels, and still others will experience minimal change in
their psychosocial functioning.
Global Assessments of Functioning and Quality of Life

Rather than focus on traditional mental health concerns and screen cancer patients with standard
psychological assessment tools, an alternate strategy is to assess the varied and unique concerns of
individuals with cancer. Consistent with the biopsychosocial approach, the strength of these instru-
ments lies in their ability to assess the impact of cancer on global functioning or overall quality of
life rather than focus on specific psychological symptoms. Quality of life is a multidimensional
construct that includes physical, psychological, social, and spiritual factors (Aaronson et al., 1991;
Tope et al., 1993). Instruments that have been developed for such use with medical patients include
the Sickness Impact Profile (Gilson et al., 1975), the Psychosocial Adjustment to Illness Scale (PAIS;
Derogatis & Derogatis, 1990), and the Medical Outcomes Study 36-Item Short Form Health Survey
(MOS SF-36; Ware, Snow, Kosinski, & Gandek, 1993). In contrast to these generic measures, other
instruments have been developed specifically for use with individuals with cancer. Table 12.1
presents a summary of six of these assessment tools.
In a comparison of women with and without a history of bone marrow transplantation for the
treatment of breast cancer, cancer patients received lower scores on six of the subscales of the SF-36
(physical functioning, physical role functioning, general health, vitality, social functioning, and
TABLE 12.1 Global Assessments of Cancer Functioning, Adjustment, and/or Quality of Life
Name of Instrument Authors and Year Description
Cancer Care Monitor Fortner (2003) 38-item, notebook computer–administered
clinical screening and quality-of-life
measure consisting of six normalized
screening measures (physical symptoms,
treatment side effects, acute distress, despair,
impaired ambulation, and impaired
performance)
Cancer Rehabilitation Schag & Heinrich (1990) 139-item, self-report measure of cancer-
Evaluation System (CARES) related problems and quality of life with five
summary scores (physical, psychosocial,
marital, sexual functioning, and medical
interaction). Short-form version is also
available
European Organization for Aaronson et al. (1993) 30-item questionnaire with five functional
Research and Treatment of scales (physical, role, emotional, social, and
Cancer–Quality of Life cognitive functioning), three symptom
Questionnaire (EORTC scales (fatigue, pain, nausea/vomiting), one
QLC-C30) global health/quality of life scale, and several
single items
Functional Assessment of Cella et al. (1993) 28-item questionnaire with four subscales
Cancer Therapy–General (physical, functional, social, and emotional
(FACT-G) well-being)
Functional Living Index–Cancer Schipper, Clinch, 22-item, self-report measure of quality of life
(FLIC) McMurray, & Levitt in which items address physical,
(1984) psychological, family, and social functioning
M.D. Anderson Symptom Cleeland et al. (2000) 13 core symptoms plus additional disease-
Inventory (MDASI) specific items evaluating the degree to which
symptoms interfere with life. It can be
administered by questionnaire or interview,
and there is current research into the
administration via interactive voice response
(IVR) system in which patients respond to
items using telephone keypad
emotional role functioning), but did not report lower levels of mental health (Hann et al. 1997).
As stated earlier in this chapter, the separation of psychological functioning from physical and
social changes that are likely to occur during the experience of cancer is a limiting conceptualiza-
tion. As a result, a broader focus on the varied changes that may be associated with the cancer
experience is appropriate.
A Third Option: Providing Interventions to All Interested Participants

Despite the appeal of an assessment tool that is able to accurately identify cancer patients most
suitable for intervention, we currently lack such an instrument. Although the assessment of more
global aspects of functioning and quality of life is an improvement over an exclusive focus on tradi-
tional mental health issues, there is another approach to consider, namely, the provision of psycho-
social oncology interventions to all interested participants. The benefits of psychosocial oncology
interventions do not appear to be limited to cancer patients with higher reports of psychological
distress. Meyer and Mark (1995) conducted a meta-analysis of psychosocial interventions with
cancer patients and found no differences associated with participants’ risk for psychological distress
or the use of psychological screening. Sheard and Maguire (1999) meta-analyzed intervention
studies in which participation was not determined by psychological screening and found moderate
and weak effect sizes for anxiety and depression outcomes, respectively. An examination of 402
cancer patients who participated in a brief group coping-skills program suggests that enhancements
of mood and quality of life did not differ by gender, marital status, religion, education, or prior
experience with mental self-help techniques, although improvements in quality of life were lower in
patients with recurrent disease (Cunningham, Lockwood, & Edmonds, 1993). It should be noted
that the benefits of group participation were not immediate in the older patients, although this
group showed equal improvement with their younger counterparts 3 months later.
Taylor, Falke, Shoptaw, and Lichtman (1986) have compared cancer patients who had and had
not participated in cancer support groups. The two groups were similar in terms of cancer site, age,
marital status, and perceived health. Those who had not participated in such groups had more
recent diagnoses, and those who had attended support groups were more likely to be of a higher
social class and to report a negative interaction with members of the medical community, prior use
of social support resources, and concerns that were both related and unrelated to the cancer experi-
ence. It is interesting to note that scores on the POMS subscales indicated no differences between
attenders and nonattenders, with the exception that those who participated in support groups were
actually less likely to report depressive symptoms.
In addition to evidence suggesting that the benefits of participation are not limited to a prese-
lected group of patients, the possibility of improved medical outcomes is a second reason why it
might be appropriate to offer interventions to all interested cancer patients. Not without method-
ological limitations, studies have linked a number of psychosocial factors with lower cancer survival
rates. This list includes lower patient-reported quality of life, higher levels of emotional distress,
greater use of depressive coping, higher levels of helplessness/hopelessness, higher pessimism
(among patients between the ages of 30 and 59), lower emotional expression, and less perceived
emotional support (Faller, Bülzebruck, Drings, & Lang, 1999; Ganz, Lee, & Siau, 1991; Reynolds et al.
2000; Schulz, Bookwala, Knapp, Scheier, & Williamson, 1996; Watson, Haviland, Greer, Davidson,
& Bliss, 1999). However, we are regularly reminded that the evidence is contradictory regarding
the relationship between psychosocial factors and cancer progression (Garssen & Goodkin, 1999;
Kidman & Edelman, 1997). For example, Dean and Surtees (1989) found that women who met the
criteria for a psychiatric illness before breast cancer surgery and those who engaged in denial after
surgery had less chance of cancer recurrence. Similarly, Fawzy and colleagues (1993) found that
higher levels of baseline mood disturbance were associated with better medical outcomes 5 to 6
years later. The causal relationship between the various psychosocial correlates of cancer and medi-
cal outcomes for cancer patients is by no means clear.
Preliminary evidence suggests that participation in psychosocial oncology interventions may be
associated with improved survival rates (Fawzy et al., 1993; Shrock, Palmer, & Taylor, 1999; Spiegel,
Bloom, Kraemer, & Gottheil, 1989). These research teams have offered various hypotheses for the
health benefits of their interventions, including greater compliance with medical treatment,
enhanced social support, improved coping and stress management, and due to a self-selection bias
or placebo effect in participation in the intervention, an increased will to live. Researchers in the
field of psychoneuroimmunology have begun exploring specific mechanisms that may be involved
(Folkman, 1999; van der Pompe, Antoni, Visser, & Garssen, 1996; Walker, Heys, & Eremin, 1999).
Research investigating a possible link between interventions and increased survival is not unequivo-
cal, and other research teams have failed to observe this relationship (Cunningham et al., 1998;
Edelman, Lemon, Bell, & Kidman, 1999; Ilnyckyj, Farber, Cheang, & Weinerman, 1994). However,
based on the results of three studies in which psychosocial oncology interventions were associated
with enhanced survival, Dreher (1997) argued that we have both scientific and moral imperatives
for the broad-based institution of interventions with this population. If we restrict participation to
cancer patients who report high psychological distress, we miss the opportunity to enhance the
quality and, possibly, the quantity of life for greater numbers of cancer patients.
Interventions for Cancer Patients
Psychosocial Interventions in the Oncology Setting

Qualitative reviewers of psychosocial oncology interventions have concluded that these interven-
tions have positive effects for individuals who participate (Andersen, 1992; Fawzy, Fawzy, Arndt, &
Pasnau, 1995; Trijsburg, van Knippenberg, & Rijpma, 1992). The results of three published meta-
analyses also indicate that participation in these interventions is associated with positive outcomes
(Devine & Westlake, 1995; Meyer & Mark, 1995; Sheard & Maguire, 1999). The interventions
included in these reviews compose a very heterogeneous group and include education, behavior
training, supportive-expressive approaches, and more structured interventions. Educational
interventions are designed to increase knowledge regarding the prevention and treatment of cancer
and the medical environment (e.g., Rainey, 1985). Mental health professionals who provide behav-
ioral interventions use relaxation training and systematic desensitization to reduce anticipatory
nausea and vomiting associated with chemotherapy and radiotherapy (e.g., Burish & Jenkins, 1992;
Morrow et al., 1992). Compas, Haaga, Keefe, Leitenberg, and Williams (1998) concluded that the
use of progressive muscle relaxation to address these treatment-related symptoms met the criteria
for an efficacious treatment. Within the less-structured approach of those who offer supportive-
expressive interventions, there is a pronounced emphasis on open sharing, self-disclosure, and
fostering high levels of cohesion (e.g., Ilnyckyj et al., 1994; Spiegel et al., 1989; Spiegel, Bloom, &
Yalom, 1981). An often-cited study is that of Spiegel and colleagues (1981, 1989) who studied the
effects of participation in a year of supportive group meetings on women with metastatic breast
cancer. Group participation was associated with significantly less mood disturbance, maladaptive
coping responses, and phobias, as well as improved length of survival.
We have chosen to focus on the final category of interventions, namely, those with a structured
cognitive behavioral approach. In these interventions, similar material is covered with each partici-
pant. Although some investigators have not detected a difference between outcomes associated with
structured versus unstructured approaches (Meyer & Mark, 1995; Worden & Weisman, 1984),
the results of other research teams point to the relative superiority of structured interventions
(Cunningham & Tocco, 1989; Helgeson & Cohen, 1996; Telch & Telch, 1986). Because mental
health professionals working in the oncology setting must consider convenience as a major factor
when offering interventions to cancer patients, we have emphasized brief structured interventions.
Regarding the duration of the interventions, unlike traditional mental health patients, medical
patients typically do not expect to remain in therapy indefinitely. Psycho-oncology researchers have
called for increased acceptability and accessibility of psychosocial interventions (Meyer & Mark,
1995; Moynihan, Bliss, Davidson, Burchell, & Horwich, 1998). One needs only to look at the rea-
sons cited for nonparticipation to understand the need for brief onsite interventions: travel
constraints, commitment to regular group attendance, and competing schedule demands (Alter
et al., 1996; Cunningham, Jenkins, Edmonds, & Lockwood, 1995; Cunningham et al., 1998). As
approximately 70% of cancer patients report feeling tired and fatigued during radiation treatment
and chemotherapy (Smets et al., 1993), it is inappropriate to expect these patients to commit to
a long-term intervention at an offsite location. In fact, positive outcomes have been associated with
brief one- or two-session interventions (Burish, Snyder, & Jenkins, 1991; Larson, Duberstein,
Talbot, Caldwell, & Moynihan, 2000). As further indication of recent awareness of the importance
of convenience, psychosocial support is now being offered via telephone (Alter et al., 1996; Marcus
et al., 1998; Mermelstein & Holland, 1991) and Internet (Sharf, 1997). In addition to patient
convenience, briefer interventions, by their very nature, are also less expensive to provide.
Brief Structured Interventions

We have reviewed 17 published psychosocial oncology interventions that followed a structured
format (Kovacs & Houts, 2004). In recognition of the need for brief interventions, our review was
limited to interventions with a maximum duration of six sessions. The total length of the interven-
tions ranged from 90 minutes to 12 hours, with an average of 6.8 hours calculated from the studies
that presented specific information regarding the duration of the intervention. Nine interventions
were administered in a group format, seven were administered on an individual basis, and one
study varied in terms of the administration. The number of participants in each study ranged from
20 to 205. Among the various studies, a wide range of cancer experiences was represented. The
average reported age of participants ranged from 40 to 65 years, and the majority of interventions
were provided to both male and female cancer patients. Thirteen of the interventions targeted
adults with newly diagnosed cancer; seven were limited to recently diagnosed cancer of specific sites
(Bridge, Benson, Pietroni, & Priest, 1988; Christensen, 1983; Fawzy, 1995; Fawzy et al., 1990a,
1990b; Larson et al., 2000; Moynihan et al., 1998; Shrock et al., 1999), and six did not have specific
inclusion criteria regarding the location of the cancer (Burish et al., 1991; Decker, Cline-Elsen, &
Gallagher, 1992; Edgar, Rosberger, & Nowlis, 1992; Ferlic, Goldman, & Kennedy, 1979; Greer et al.,
1992; Worden & Weisman, 1984). In the remaining four studies, each sample was heterogeneous in
terms of cancer site and time since diagnosis (Cunningham et al., 1995; Cunningham & Tocco,
1989; Heinrich & Schag, 1985; Telch & Telch, 1986).
In our review, we classified the treatment components of each structured intervention into a
10-category system. Rather that looking for unique contributions of the individual interventions,
the goal was to discern common features. However, it was not a simple process to categorize the
treatment components, as there was extreme variation in the attention that researchers devoted to
explaining the specific content of their interventions (an observation also made by Andersen,
1992). Table 12.2 presents a brief description of each of the categories along with their frequency
among the 17 reviewed brief structured interventions.
As is evident from Table 12.2, the majority of the interventions included relaxation training,
and progressive muscle relaxation (PMR) was the most common technique. In standard PMR, an
individual alternates between tensing and relaxing specific muscle groups in order to produce
an increased sense of physical relaxation. There are many published PMR scripts (e.g., Davis,
Eshelman, & McKay, 1995), the majority of which are variations of Jacobson’s (1929) original
program. Some of the interventions added visual imagery, and it has been observed that this
addition may be useful for cancer patients with physical limitations that make muscle contraction
difficult (Edgar et al., 1992). When participants in one study were asked what they perceived to be
the most helpful components of the interventions, relaxation training was the most common
response (Heinrich & Schag, 1985). However, although the participants may have appreciated
relaxation training, this does not imply that they actually increased their overall sense of relaxation.
No studies included an assessment of subjective physical relaxation, and blood pressure and heart
rate were assessed in only one study (Burish et al., 1991).
TABLE 12.2 Common Components of Brief Structured Interventions (N = 17)

Recommended Number of
Component Description References Studies
Relaxation training Training in specific techniques Davis, Eshelman, & McKay 15 (88%)
to increase sense of relaxation (1995); Horowitz &
(e.g., progressive muscle Breitbart (1993)
relaxation, visual imagery,
deep breathing)
Problem solving Training in specific problem-solving Fawzy & Fawzy (1994) 10 (59%)
approaches and the application to
personal situations, or the
identification of areas of desired
change followed by discussion or
behavioral practice in order to
enact change
Supportive discussion Specific allotment of time for Classen et al. (1997); 10 (59%)
informal discussion, specific Spiegel, Bloom, & Yalom
reference to within-group (1981)
support, or specific stated
objective of provision of
psychological support or
supportive discussion
Education Provision of information Burish, Snyder, & Jenkins 9 (41%)
(e.g., cancer and its treatment, (1991); Ferlic, Goldman,
health-care system, impact & Kennedy (1979)
of stress) without skills training
or application of this knowledge
Cognitive therapy Identification of maladaptive Beck (1995); Edgar, 7 (41%)
thought patterns and the Rosberger, & Nowlis
promotion of more effective (1992)
ways of thinking
Stress management Assessment of individual’s stress, Davis, Eshelman, & McKay 7 (41%)
stress monitoring, or the provision (1995); Fawzy & Fawzy
of strategies to improve coping (1994)
with stress
Activity/lifestyle Completion of lifestyle checklist Davis, Eshelman, & McKay 7 (41%)
management and discussion of health lifestyles, (1995)
increased engagement in pleasant
events, or exercise
Communication skills Promotion of effective Christensen (1983) 4 (24%)
communication (e.g., between
patient and spouse), which may
include the open expression of
feelings during sessions
Goal setting Instruction in principles of effective Davis, Eshelman, & McKay 3 (18%)
goal-setting in order to organize (1995); Cunningham et al.
priorities or provide sense of (1991)
accomplishment/control

Healing imagery Visualization of effective functioning Cunningham et al. (1991) 3 (18%)
of immune system or patient’s body
overcoming cancer
Note. Adapted from Kovacs and Houts, in press.
In addition to relaxation training, the intervention components that were administered with
greatest frequency were problem solving, supportive discussion, and education. It is worth noting
that not all the interventions that offered problem-solving training assessed problems faced by
cancer patients or participants’ abilities to cope with or adjust to problems, and not all the interven-
tions that provided education assessed whether there was any improvement in the knowledge of the
participants. Therefore, it appears that there has not been adequate assessment of whether these
interventions produce the changes that the developers targeted.
In addition to often neglecting to provide adequate information on the specific content of the
interventions, researchers did not always provide a clear theoretical rationale for the development
of their intervention. Although replication is important to determine the efficacy of an intervention
(Compas et al., 1998), the current practice results in a lack of development of more novel approaches.
As an example, participants in 15 of the 17 interventions received at least one form of relaxation
training. Mental health professionals working in the cancer setting may therefore assume that relax-
ation training is an essential component of an intervention. This is a premature assumption,
however, as there is a paucity of research comparing interventions that offer relaxation training with
those that do not. In fact, in one study that compared the impact of a 90-minute multicomponent
preparatory intervention, multiple relaxation training sessions, and a combined intervention con-
sisting of the preparatory intervention and relaxation training, it was observed that the single ses-
sion was the most effective at increasing knowledge and reducing nausea, hostility, depression, and
interference in daily and work lives (Burish et al., 1991). Although it is inappropriate to eliminate
relaxation training in psychosocial oncology interventions based on the results of a single study,
this does suggest that further investigation is necessary in order to determine whether the seemingly
automatic inclusion of relaxation training is warranted.
This commentary was not offered to suggest that the commonly used treatment components are
not useful. In fact, in 16 of the 17 brief interventions that were reviewed, research teams observed
positive outcomes associated with participation. In addition to reductions in reported psychosocial
distress, various research teams also found that individuals who participated in the interventions
experienced less interference in daily and work lives, fewer and less severe problem situations,
enhanced problem solving, adjustment to cancer, and quality of life, and improved survival rates.
A list of common intervention components was included in order to provide a starting base for
mental health practitioners and provide an impetus for researchers in this area.
Summary
This chapter was primarily directed toward mental health professionals who wish to integrate
interventions in the oncology setting. For individuals who plan to establish a full psycho-oncology
unit within a cancer setting, however, the process will be more involved. Jimmie Holland (1998),
founder of the Memorial Sloan-Kettering psycho-oncology program in New York, has offered
guidelines for individuals who wish to undertake this project. Holland provided information for
the development of a unit proposal and mission statement, staff recruitment, development of ties
with community organizations, working within the traditional oncology setting, establishing
educational and research programs, and advocacy and ethical issues. As the provision of a psycho-
oncology unit is likely beyond the scope of the majority of readers, we have focused on the
more general concerns of individuals interested in offering a psychosocial intervention to cancer
patients.
When considering assessment strategies, it is important to maintain a biopsychosocial approach
and recognize the varied impacts of cancer. There are physical and social changes associated with
cancer diagnoses and treatment, and there likely exists a continuum of psychological well-being
among cancer patients. Although this chapter reviewed evidence to suggest that the majority of
cancer patients do not experience significant psychological disturbance, the aim was not to
suggest that we neglect true psychological disturbance among the minority of cancer patients who
experience it. Mental health professionals working in the oncology setting must be prepared to deal
with cancer patients who experience serious emotional problems. The practice of traditional psy-
chological screening, however, is not likely to serve as an effective way to identify these individuals. In
addition, although clinically depressed and anxious cancer patients require increased attention, this
does not mean that we should neglect other patients who may be experiencing significant changes
in other areas of functioning.
As to the actual intervention, it is important to select treatment components that reflect the
goal of the intervention. As stated earlier, some mental health researchers have limited participa-
tion to cancer patients who reported high levels of emotional distress. Therefore, these studies
explicitly targeted the presumed psychological distress of cancer patients. However, with a primary
focus on the emotional impact of cancer, mental health professionals run the risk of minimizing
other aspects of cancer, such as fatigue, sleep disturbance, pain, and changes in interpersonal func-
tioning. Although psychological interventions that address the stresses associated with cancer,
teach relaxation training, or reduce sleep-related anxiety have been recommended (Berlin, 1984;
Horowitz & Breitbart, 1993), none of the brief interventions in this review included assessments
of their ability to improve sleep in cancer patients. Thomas and Weiss (2000) encouraged the use
of psychoeducation, supportive psychotherapy, and cognitive behavioral therapy, in addition to
traditional pharmacotherapy, to target cancer pain. Mental health professionals who are planning
to introduce psychosocial interventions in an oncology setting may find it useful to consider the
options included in Table 12.2. The focus need not be limited to this list. The inclusion of novel
treatment components with a strong theoretical rationale is also encouraged. For example, opti-
mism is one factor that has been associated with fewer reported symptoms of mood disturbance,
anxiety, and depression as well as more effective coping and higher self-esteem (Bjorck, Hopp, &
Jones, 1999; Carver et al., 1993; Epping-Jordan et al., 1999). Mental health professionals may
wish to offer interventions with the intention of enhancing the optimism of cancer patients. Of
the 17 studies in our review, four research teams expanded their focus beyond psychosocial vari-
ables and investigated the effects of psychosocial oncology interventions on physiological or health
outcomes (Burish et al., 1991; Fawzy et al., 1990b, 1993; Larson et al., 2000; Shrock et al., 1999).
Among these studies, outcome measures included immunological functioning, blood pressure,
heart rate, self-reported health, self-reported ratings of nausea and vomiting, and survival or
recurrence rates several years later. This type of unique combination of both physical health out-
come measures and psychosocial functioning outcome measures needs to be promoted in future
investigations.
In summary, the adoption of a biopsychosocial perspective to cancer is crucial in order to under-
stand the impact of cancer diagnoses and treatment. The negative impact of cancer on an individ-
ual’s overall quality of life and the possible role of psychology in minimizing this disruption are
receiving increasing attention. For this reason, this is an exciting time for both clinicians and
researchers interested in the expanding role of psychology within the oncology setting.
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Chapter 13
Managing Obesity in Primary Care
MARK W. CONARD, WALKER S. CARLOS POSTON, AND JOHN P. FOREYT
Obesity is a major health problem in the United States and other industrialized nations (Mokdad
et al., 2004; NHLBI, 1998). Obesity has been traditionally defined as an excess of body fat (i.e., 25%
body fat in men and 33% in women; Bray, 1998). This increased body fat is associated with greater
risk for a number of health problems including cardiovascular disease, diabetes, and some cancers
(Anderson & Wadden, 1999). The prevalence of obesity in primary care appears to be high due its
increasing rates in the general population as well as in individuals with obesity-associated medical
conditions (e.g., type 2 diabetes, dyslipidemia, and hypertension) seeking treatment (Gray, 1999),
with many obese patients (from 50% to 75%) reporting not receiving advice from their health-care
providers regarding weight management strategies (Galuska et al., 1999; Potter, Vu, & Croughan-
Minihane, 2001; Stafford, Farhat, Misra, & Schoenfeld, 2000). A recent study of family practice
offices found that 64% of the patients were obese (Gray, 1999), With such large-scale prevalence,
obesity management and treatment should be seen as a problem requiring the involvement of pri-
mary care providers as well as specialists in the field.
Obesity Prevalence in the United States

At the present time, 61% of the adult population in the United States is either overweight (i.e., body
mass index [BMI] of 25 to 29.9) or obese (a BMI of 30 or more) (CDC, 2000). Approximately 34%
are overweight and 27% are obese. These data indicate a 14-percentage-point increase since 1980.
The highest prevalence is within the minority population, with 36.5% of African American women
and 33.3% of Mexican American women obese. In contrast, the lowest prevalence is in Caucasian
men (20.0%) and African American men (20.6%) (Foreyt & Pendleton, 2000). Although obesity
prevalence typically increases through age 59 and then declines, the rate of obesity in children is
increasing rapidly, with estimates ranging from 20–30% (Gortmaker, Dietz, Sobol, & Wehler, 1987;
Troiano & Flegal, 1998). Various studies have noted significant increases in the prevalence of obe-
sity in children over the past several decades. The Bogalusa heart study found that among 6-to-11-
year-olds, there has been a 50% increase in the rates of obesity since 1973 (Freedman, Srinivasan,
Valdez, Williamson, & Berenson, 1997). Another study reported that there has been an 80%
increase in the incidence of obese children becoming obese adults (Schonfeld-Warden &
Warden, 1997). Adults with childhood onset of obesity have more severe obesity and earlier onset
253
of co-morbidities. The likelihood of an obese child becoming an obese adult increases as children
age and remain obese (Foreyt & Pendleton, 2000).
Costs of Obesity
In the United States, the costs of obesity were estimated to be $99.2 billion in 1995 with approxi-
mately $51.6 billion being direct medical costs associated with the treatment of obesity-related
diseases (NHLBI, 1998). These direct costs represented about 5.7% of the national health expendi-
ture within the United States (Wolf & Colditz, 1998). The indirect costs, which represent the value
of lost output caused by morbidity and mortality, the effects of other medical conditions, and the
personal and societal level impacts of obesity, were $47.6 billion (Wolf & Colditz, 1998). For example,
cardiovascular disease and type 2 diabetes accounted for 48% and 17.5%, respectively, of the
indirect costs (Colditz, 1999).
In a study of the relationship between BMI and future health-care costs, individuals with BMIs
of 20 to 24.9 had averaged total costs of outpatient services of $7,673, inpatient care of $5,460,
pharmacy services of $2,450, and of all medical care of $15,583 over the 8-year period of the inves-
tigation (Thompson, Brown, Nichols, Elmer, & Oster, 2001). In contrast, for those with BMIs of 30
or greater, the averaged total costs of outpatient services was $8,826, for inpatient care was $7,885,
use of pharmacy services was $5,000, and total medical costs were $21,711.
Other researchers reported that average annual total costs were 25% higher among individuals
with BMIs of 30 to 34.9 (mild obesity) and 44% higher among those with BMIs of 35 or greater
(moderate to severe obesity) compared with normal-weight individuals (Quesenberry, Caan, & Jacob-
son, 1998). Similar results were obtained by Pronk, Tan, and O’Connor (1999), who found that the
expected mean annualized costs were approximately 12% higher for those individuals with BMIs of
30 to 34 and approximately 19% higher for those with BMIs of 35 to 39 compared with normal-
weight individuals.
In contrast, the cost offsets of intervention programs to lower obesity have had positive eco-
nomic effects (Pronk et al., 1999). Shephard (1992) investigated the economic impact of a physical
activity intervention and found that after 12 years of operation, the intervention yielded a $6.85
return for every $1.00 invested. In addition, the intervention saved $679 in medical costs per year
for each participant. Pronk et al. (1999) found similar results for the effects of physical fitness on
lowering obesity costs.
Etiology of Obesity
Obesity is a complex, multifaceted chronic disease that involves metabolic, physiological, biochem-
ical, genetic, behavioral, social, and cultural factors (Foreyt & Pendleton, 2000). It is a result of an
imbalance between the energy individuals expend and the amount of calories they consume.
However, public opinion has tended to view obesity as the result of gluttony and sloth, a behavioral
disorder of overeating and laziness (i.e., obese individuals would lose weight if they would just eat
less and exercise). There is some basis for this belief. For example, Americans have become more
sedentary in both work and leisure (USDHHS, 1996). In addition, Americans consume about 150
more calories per day than they did 10 years ago (Poston & Foreyt, 1999). However, these are not
the only reasons behind the epidemic of obesity.
Research has suggested that there is a substantial genetic component to obesity. Genetic influ-
ences have been found to contribute to differences among resting metabolic rate (Rice, Tremblay,
Deriaz, Perusse, Rao, & Bouchard, 1996), body fat distribution (Bouchard, Perusse, Rice, Rice, &
Rao, 1998), and weight gain in response to overfeeding (Bouchard et al., 1990). Some individuals
appear to be more predisposed to obesity than others. Thus, environmental factors that interact
Managing Obesity in Primary Care • 255
with obesity-promoting genes have become more available and salient in today’s society (Poston &
Foreyt, 1999).
Health Risks of Obesity

Increasing body mass is associated with greater mortality risk (NHLBI, 1998; Solomon & Manson,
1997; Mokdad et al., 2004; Pi-Sunyer, 2002). Figure 13.1 provides a graphical representation of the
relationship between increased BMIs and mortality rates.
Obesity increases the risk of cardiovascular disease–related mortality one- to twofold (NHLBI,
1998; Singh & Linstead, 1998). A study of coronary patients found that a BMI greater than 35 was
associated with an increase in mortality risk (Ellis, Elliott, Horrigan, Raymond, & Howell, 1996).
Obesity has been found to contribute to an increased risk of multiple co-morbid medical condi-
tions including hypertension, dyslipidemia, coronary heart disease, type 2 diabetes, gallbladder
disease, sleep apnea, osteoarthritis, various forms of cancer, pulmonary problems, and complications
with pregnancy (Ellis et al., 1996; Gray, 1999; Mokdad et al., 2003; NHLBI, 2002; Pi-Sunyer, 2002).
Individuals with BMIs of 30 or more are substantially more likely to have some co-morbid condition
compared with individuals with BMIs of 19.0 to 24.9 (Quesenberry et al., 1998). Obese patients are
1.7 times more likely to have heart disease, 2 times more likely to have hypertension, and 3 times more
likely to have type 2 diabetes compared with normal-weight individuals (Quesenberry et al., 1998).
2.5
All women
Women who never smoked

2.0
Relative Risk of Overall Mortality
Women who never smoked

and recently had stable weight
1.5
1.0
0.5
<19.0 19.0-21.9 22.0-24.9 25-26.9 27-28.9 29-31.9 ≥32.0
Body Mass Index
Fig. 13.1 Relationship between mortality and BMI. When mortality risk is adjusted for disease-related
health status and smoking, the leanest women (BMI < 20) have the lowest mortality and that mortality risk
increases with increasing BMI (adapted from WHO, 1998).
With the increase in obesity, it is not surprising that primary care physicians are seeing more
co-morbidities. What we do not know is how frequently primary care physicians are treating the
obesity or focusing only on the co-morbid conditions.
Assessment of Obesity
Before prescribing weight loss intervention, primary care providers should assess the patient’s level
of obesity, need for treatment, and readiness for change. Assessment will help determine the type of
treatment to prescribe and how to best tailor interventions to each patient’s needs. Areas of assess-
ment involve determining the degree of obesity, level of health risk involved, current diet and eating
patterns, level of physical activity, emotional state, and readiness to change. These assessments are
warranted when the physician believes the patient is presenting with early signs and symptoms of
obesity or associated co-morbid medical conditions that require attention.
Assessing the degree of obesity provides the practitioner a useful starting point for selecting the
most appropriate treatment modality (Foreyt & Pendleton, 2000). For example, cognitive behav-
ioral techniques have been used most often with patients who are overweight to moderately obese
(BMIs from 25–40), while other approaches, such as gastric bypass surgery, have been indicated for
patients with severe obesity (BMI greater than 40) (NHLBI, 1998).
Assessment Tools
There are numerous assessment tools for determining the degree of obesity or body fatness of a
patient. These tools include hydrodensitometry (underwater weighing), air displacement plethys-
mography, dual x-ray absorptiometry (DEXA), isotope dilution, total body potassium, skin-fold
measurements, bioelectrical impedance, ultrasound, total body conductivity (TOBEC), computed
tomography (CT), magnetic resonance imaging (MRI), neutron activation, waist circumference,
and BMI (Foreyt & Pendleton, 2000; NHLBI, 2000).
Hydrodensitometry. In hydrodensitometry, the patient is weighed on a special scale while completely

submerged underwater. The technique is based on the principle that fat floats and nonfat components
sink. This method was the “gold standard” until the advent of dual x-ray absorptiometry (DEXA).
Dual X-Ray Absorptiometry. The DEXA method requires patients to lie on a table while low-energy
x-rays are beamed through their bodies. Estimates of lean body mass, body fat, and bone content
are possible. The cost of the DEXA equipment ranges from $40,000–100,000. Patients weighing in
excess of 300 pounds may not be testable because of the structural limitations of the equipment
(Foreyt & Pendleton, 2000).
Skin-Fold Measurements. The skin-fold method entails the measurement of subcutaneous fat at
predefined points on the body utilizing a special pincher-like device known as a skin caliper (Foreyt
& Pendleton, 2000). Skin-fold measurements are one of the more common, inexpensive methods of
estimating body fat because of the ease of administration. However, there are concerns regarding
the skin-fold method’s accuracy as compared with hydrodensitometry and DEXA because of varia-
tion in measurement instrumentation and difficulties with interrater reliability. Another limitation
of the method is related to the inability of the jaws of the calipers to open wide enough to measure
extremely large deposits of fat.
Bioelectrical Impedance. Bioelectrical impedance uses a weak electric current to determine the
level of body fat in the patient (Foreyt & Pendleton, 2000). This weak electric current is passed
through the body with the current flow being aided by hydrated, fat-free tissue and impeded by
dense adipose tissue. Thus, the more body fat, the more inhibited and slower the current. Although
this technique is advanced in its use of technology, it appears to be less accurate than DEXA because
it is sensitive to the patient’s level of hydration.
Imaging Techniques. Several imaging techniques have been found to be useful in assessing body fat
(Foreyt & Pendleton, 2000). One technique is a portable ultrasound meter. It measures subcutaneous
fat using sound reflectance. Ultrasound has good reliability and is not limited by the size of the
patient being assessed. Another technique is TOBEC, which relies on the change in electromagnetic
characteristics as a function of fat and water. Other imaging methods that are accurate in measuring
body fat are CT and MRI. However, similar to DEXA, CT, MRI, and TOBEC, the imaging equip-
ment is expensive and in clinical settings these costs might be restrictive. Less-expensive methods
such as skin-fold measurements and ultrasound can produce results with 95–97% accuracy when
performed according to recognized protocols (McArdle, Katch, & Katch, 1991).
Waist Circumference. Waist circumference is positively correlated with abdominal fat content
(NHLBI, 1998). This method provides a clinically acceptable measurement for determining a
patient’s abdominal fat content. Sex-specific cutoffs have been determined to identify the increased
relative risk for the development of obesity-related risk factors in most adults with BMIs of 25 to
34.9. High-risk cutoffs for men and women are a waist circumference greater than 102 cm (greater
than 40 in.) and 88 cm (greater than 35 in.), respectively.
Body Mass Index (BMI). A quick method to determine the level of obesity is to assess BMI, which
is determined by taking weight in kilograms and dividing it by height in meters squared (NHLBI,
1998). BMI also can be calculated by dividing weight in pounds by height in inches squared and
multiplying the product by 704.5 (as shown in the Nonmetric Formula for Calculating BMI, Equa-
tion 13.1). Table 13.1 provides a BMI chart commonly used to assess obesity.
Weight ( pounds )
BMI = × 704.5
Height (inches )2
BMI has been divided into classes to define underweight (BMI less than 18.5), normal weight
(BMI 18.5–24.9), and overweight (BMI 25–29.9) individuals (see Table 13.2). For obesity (BMI 30
or greater), there are three further classifications divided in terms of severity: Class I—mild obesity
(BMI of 30.0 to 34.9), Class II—moderate obesity (BMI of 35.0 to 39.9), and Class III—severe
obesity (BMI of 40 or greater) (NHLBI, 1998). The advantages of using the BMI in primary care
include its ease of use, its accuracy in measuring both weight and height, and its use of similar criteria
independent of gender (Foreyt & Pendleton, 2000). However, BMI does not work well with well-
muscled athletes who have unusually high levels of lean muscle mass. In addition, the BMI categories
are restricted to individuals who are past puberty. Classifying children using BMI could result in
incorrect estimations of their body composition (McArdle et al., 1991).
Health Risk Assessment

Figure 13.1 indicates the relationship between BMI and increased mortality. As illustrated by the
figure, higher BMIs tend to be associated with higher rates of mortality. With the increased preva-
lence of other medical conditions that are related to obesity, it is important to assess the level
of health risk of the patient. Some obese patients with multiple health risks need to lose weight
more than patients who are otherwise relatively healthy. Likewise, heavier patients usually have
more co-morbid medical conditions than those who are not as heavy.
TABLE 13.1 Example of Body Mass Index (BMI) Chart
TABLE 13.2 Classification of Obesity Using BMI

BMI
Underweight < 18.5
Normal weight 18.5–24.9
Overweight 25–29.9
Mild obesity 30–34.9
Moderate obesity 35–39.9
Severe obesity > 40
Diet/Eating Patterns Assessment

Because diet plays a major role in the development of obesity, an assessment of dietary patterns is an
essential component for devising a treatment plan (Foreyt & Pendleton, 2000). However, the labor-
intensive nature of traditional assessment techniques (i.e., 24-hour recall and food-frequency ques-
tionnaires) challenges the primary care provider’s ability to deliver quality service in a time-efficient
manner. In response, brief dietary assessment questionnaires have been developed. These question-
naires include the MEDFICTS Dietary Assessment Questionnaire (National Cholesterol Education
Program, 1993), the Rate Your Plate dietary assessment questionnaire (which aims at the management
of cholesterol) (SCORE, 1988), and the Eating Pattern Assessment Tool (which is directed at patients
interested in maintaining a heart-healthy diet) (Physician Based Nutrition Program, 1990).
These tools assess the frequency at which certain food groups are eaten per week along with
typical serving sizes (Foreyt & Pendleton, 2000). Although these tools are specific to particular
medical conditions, they can be generalized easily to obesity management because they provide a
description of the patient’s daily eating patterns. An advantage of these brief tools is that the
primary care provider can capture reliable and general data concerning the patient’s eating patterns
in a relatively short time. In addition, patients gain self-awareness of their eating behaviors.
If more detailed dietary patterns are required, primary care physicians can refer the patient to a
registered dietitian.
Physical Activity Assessment

Similar to assessing dietary patterns, examining the patterns and levels of physical activity can
augment treatment planning. However, like traditional dietary assessments, these techniques tend
to consume large amounts of time (Foreyt & Pendleton, 2000). To shorten the assessment, more
cost-effective methods to examine a patient’s physical activity have been developed. For example,
general patterns of physical activity can be efficiently assessed by the Self-Administered 7-Day
Physical Activity Recall Questionnaire (Blair, 1984). The instrument provides a means of capturing
general information concerning the patient’s level of moderate-to-vigorous physical activity over
the most recent 7-day period.
Emotional Assessment
The assessment of a patient’s emotional state is important in determining the proper treatment for
obesity. About 25–30% of obese patients who seek some form of weight reduction therapy report-
edly suffer from marked depression or other psychological disturbances (Fitzgibbon, Stolley, &
Kirschenbaum, 1993). There also is a high prevalence of depression among obese patients who
binge (Marcus, 1993), along with increased emotional distress (Yanovski, 1993). Patients suffering
from depression tend to have more difficulty in adhering to weight management programs and may
achieve greater success if the depression is treated effectively before a weight loss program is imple-
mented (Foreyt & Pendleton, 2000). Obese patients with marked depression, anxiety, or binge
eating may require some form of psychotherapy or pharmacotherapy before beginning any form of
weight loss treatment (Anderson & Wadden, 1999).
There are several well-documented instruments that can aid in assessing depression, including
the Beck Depression Inventory for Primary Care (BDI-PC; Steer, Cavalieri, Leonard, & Beck, 1999)
and the Center for Epidemiologic Studies Depression Scale (CES-D; Miller & Harrington, 1997a).
The BDI-PC is a self-administered, 7-item questionnaire that reliably identifies depression in a
primary care setting (Steer et al., 1999). The CES-D also is self-administered. It contains 20 items
with good psychometric properties and is simple to use (Miller & Harrington, 1997a).
In addition to assessment instruments for depression, there also are brief and valid measures of
general distress, anxiety, and binge eating available. For example, the General Well-Being Schedule
is an 18-item questionnaire that was developed to measure well-being and distress as part of
the U.S. Health and Nutrition Examination Survey (McDowell & Newell, 1987). It has established
cut points, and its reliability and validity have been evaluated in a variety of populations (Miller &
Harrington, 1997b; Poston et al., 1998; Taylor et al., 2003). For assessment of anxiety, a well-known
and brief measure is the State-Trait Anxiety Inventory (Spielberger, Syderman, Owen, & Marsh,
1999). This brief measure assesses both state (situation specific) and trait (general) anxiety symp-
tom ratings and has been studied in a number of relevant patient samples (Spielberger et al., 1999).
Finally, the Binge Eating Scale is a 16-item questionnaire designed to assess distress associated with
binge eating and severity of bingeing. Although it is not equivalent to a diagnosis of binge-eating
disorder, it has been found to be a useful outcome measure in obesity and binge-eating intervention
studies and has established norms and validity data (Gormally, Black, Daston, & Rardin, 1982; Pike,
Loeb, & Walsh, 1995; Stellefson & O’Neil, 1997).
Stages of Change Assessment

A final area that should be assessed by the primary care provider before developing a treatment
plan is to examine the patient’s readiness for change (Foreyt & Pendleton, 2000). For any type of
therapy or treatment to be effective, the patient needs to be motivated to make the appropriate
changes. Obese patients will present at differing levels of readiness to change. It is likely that some
severely obese patients with multiple medical conditions will not be ready to change their habits to
reduce their weight. The primary care provider needs to recognize this fact and work with these
patients to educate them about the issues involved.
The Transtheoretical Model (or Stages of Change Model) categorizes individuals into five stages:
precontemplation, contemplation, preparation, action, and maintenance (Prochaska, Norcross, &
DiClemente, 1994). Precontemplators are individuals who are not at all concerned about their
obesity. Contemplators express some concerns about their weight but are not yet certain about
taking some type of action. For example, if obese patients are not ready to begin reducing their
caloric intake and increasing their exercise, such suggestions will fall on deaf ears and may even
increase their resistance. In this instance, discussion between the primary care physician and the
obese patient focused on education and personalization of the risks involved might be more beneficial.
Individuals in the preparation stage have decided to make some change but have not yet done so.
These individuals need encouragement to take action as well as to make a commitment to change
their behaviors. Individuals in the action stage recently have started to make changes in their habits
and tend to benefit most from behavioral interventions such as goal setting and self-monitoring
(Foreyt & Pendleton, 2000). Obese patients in the maintenance stage are working on continuing the
changes they have made and tend to benefit from moral support and recognition.
To assess the level of readiness of an obese patient, primary care physicians can use the questions
developed by Prochaska and colleagues (1994). Table 13.3 illustrates some diagnostic questions that
could be used to assess a patient’s current stage of change with respect to dieting behaviors.
Similar questions can be used to assess various target behaviors. Recently, a study was conducted
using this method to assess stages of change of six weight-related behaviors among a group of obese
patients at a family practice clinic (Logue, Sutton, Jarjoura, & Smucker, 2000). The researchers
found that patients in a particular stage were distributed across all five stages for other behaviors.
The stage of change was associated significantly with BMI or waist girth.
A shortened form of the University of Rhode Island Change Assessment Scale (URICA) relates
the stages of change to weight management (Prochaska & DiClemente, 1992). It consists of four
dichotomous items that relate precisely to weight management behavior. One study using this
assessment tool found that obese individuals in the precontemplation and contemplation stages
were more likely to have negative feelings toward weight management strategies, while those in the
action stage were more likely to have positive, directed coping approaches (Cowan, Britton, Logue,
Smucker, & Milo, 1995).
Treatment Strategies for Obesity
Psychosocial Treatments
In working with obese patients, a central component of management and treatment is the modifi-
cation of the patient’s lifestyle. The focus is on increasing physical activity, normalizing caloric
TABLE 13.3 Examples of Stages of Change Questions for Dieting Behaviors

Which statement most accurately describes you?
Precontemplation—I do not diet and have no plans to start.
Contemplation—I plan to begin dieting in the next 6 months.
Preparation—I plan to begin dieting in the next month.
Action—I have begun dieting on a regular basis for more than 6 months.
Maintenance—I have been dieting on a regular basis for more than 6 months.
consumption, and creating realistic expectations for success. There are seven basic lifestyle modifi-
cation approaches used to decrease caloric consumption and to increase physical activity: setting
realistic goals, self-monitoring, stimulus control, cognitive restructuring, stress management,
relapse prevention training, and social support (Foreyt & Pendleton, 2000).
Setting Realistic Goals. A patient will, on average, lose 8–10% of baseline weight in an intervention
program, but most obese patients want to lose more. Therefore, an important early treatment strategy
is to assist patients in setting more realistic weight-loss goals. For example, a physician might
encourage a patient to make small behavioral changes in eating and physical activity and to concen-
trate on the health benefits associated with these changes (Foreyt & Pendleton, 2000). This type of
approach provides the patient with dual benefits, including feelings of success for meeting the
short-term goals as well as moving toward the long-term goal of weight loss that can be maintained
(Foreyt & Pendleton, 2000).
Self-Monitoring. One of the most of important lifestyle modification strategies is self-monitoring

(Foreyt & Pendleton, 2000). Self-monitoring involves the systematic observation and recording of
specific target behaviors, related feelings, and environmental cues (Baker & Kirschenbaum, 1993).
This technique is particularly useful for someone attempting weight loss because it raises the aware-
ness of the patient’s eating behaviors and levels of physical activity as well as what affects these
behaviors. Self-monitoring tools include food diaries to record total caloric intake, total fat grams
consumed, food groups used, and situations when overeating is common; physical activity logs to
record frequency, duration, and intensity of exercise; electronic devices that count the number of
steps taken; and weight scales or body composition measures to record changes in weight, body fat,
or lean body mass (Poston & Foreyt, 1999).
Accuracy in self-reporting of behaviors is desirable but does not usually occur, and absolute
accuracy is not necessary (Foreyt & Pendleton, 2000). This strategy is beneficial even with some
inaccuracy (i.e., patients tend to underestimate caloric consumption by about one-third and over-
estimate physical activity by about one-half) because it provides an increased awareness of eating
and physical activity behaviors possibly leading to some type of improvement (Foreyt & Goodrick,
1991; Foreyt & Poston, 1996). Self-monitoring strategies have been found to be consistently
effective in improving treatment outcomes, with patients reporting that they are one of the most
helpful tools in obesity management (Baker & Kirschenbaum, 1993; Boutelle & Kirschenbaum,
1998; Kayman, Bruvold, & Stern, 1990). However, physicians tend not to ask their patients to
keep food diaries, and patients do not like to fill them out even though diaries are the single most
helpful tool for raising patients’ awareness of their eating and physical activity behaviors (Foreyt &
Pendleton, 2000).
Stimulus Control. Stimulus control involves the identification and modification of the environmental
cues that contribute to overeating and inactivity (Baker & Kirschenbaum, 1993). Once the
environmental cues have been identified, patients can devise strategies to control them, which can
be useful in maintaining long-term weight loss (Foreyt & Goodrick, 1993). Various techniques to
help control common environmental cues include eating only at the kitchen table without watching
television, keeping no snack foods in the house, and placing exercise clothes out the night before as
a reminder to jog in the morning.
Cognitive Restructuring. Cognitive restructuring refers to encouraging patients to examine their

inner thoughts, feelings, and beliefs about themselves and their weight and challenging them to
change those beliefs that are inaccurate or counterproductive (Foreyt & Goodrick, 1993). This
method is particularly useful with obese patients because many of them have poor self-esteem and
distorted body images. Some are unrealistic about how much weight they can lose as well as the
benefits of weight loss (Poston & Foreyt, 2000). The goal of cognitive restructuring is to identify
these self-defeating cognitions and to assist the patient in replacing them with more productive and
affirming ones (Foreyt & Pendleton, 2000).
Stress Management. Stress management training is useful in the management of weight loss
because stress has been found to be a strong predictor of overeating and relapse (Kayman et al.,
1990; Pendleton et al., 2001). There are a number of techniques to manage stress and reduce associ-
ated sympathetic nervous system arousal. These techniques include diaphragmatic breathing, stress
innoculation training, progressive muscle relaxation, and meditation (Poston & Foreyt, 2000).
They have been found to be highly effective in helping manage a number of health-related prob-
lems including obesity (Everly, 1989).
Relapse Prevention. Relapse prevention training attempts to normalize lapses as an acceptable part
of weight-loss management (Foreyt & Goodrick, 1991, 1994). The method teaches patients to
accept lapses as inevitable and prepares them to manage lapses by minimizing the damage and
getting patients back on the road to weight loss as quickly as possible. This technique lessens the
chance that a full relapse will occur.
Social Support. Research consistently has shown that patients with high levels of social support
tend to have greater success in achieving and maintaining weight losses than those lacking in
support (Kayman et al., 1990). High levels of social support also improve adherence to obesity
management programs (Foreyt & Goodrick, 1991; Klem, Wing, Simkin-Silverman, & Kuller, 1997).
Improving social support involves including family members and friends in the weight loss inter-
vention, participation in community-based programs, involvement in outside social activities
(e.g., university or community education courses, health clubs, and church-related activities), or
referrals to groups of individuals with similar goals (Foreyt & Pendleton, 2000; Poston & Foreyt,
2000). Social support helps patients become more self-accepting, develop new norms for interper-
sonal relationships, and manage stressful work- or family-related situations (Foreyt & Goodrick,
1993; Kayman et al., 1990).
Results of Behavioral Interventions

Incorporating lifestyle modification strategies into obesity management programs produces
average weight losses of about 10 kg (22 lb) over 6 months (Poston & Foreyt, 2000). Intervention
programs last about 20–24 weeks and usually including multiple treatment strategies. Patients tend
to maintain, on average, about two thirds of their initial weight loss 9 to 10 months after the termination
of their treatment. Although 5–10% losses of initial bodyweight can confer health benefits, it is not
known how long these health benefits last or how quickly the gradual weight gain after treatment
termination mitigates these benefits (NHLBI, 1998). Attrition rates are generally low (less than
18%). There is greater weight loss when multiple lifestyle modification strategies are used (NHLBI,
1998; Wing, 1998).
Physical Activity
Physical activity is associated with reductions in a number of co-morbid, obesity-related medical
conditions. It is an important predictor of weight maintenance (NHLBI, 1998; USDHHS, 1996).
The type, frequency, intensity, and duration should be considered when adding physical activity to
a weight loss program (Foreyt & Pendleton, 2000; Miller & Wadden, 2004). The types selected
should be matched to the individual’s physical and psychological limitations to ensure consistency
and enhance adherence.
The American College of Sports Medicine has recommended specific guidelines for exercise-
induced weight loss (Jakicic et al., 2003). These guidelines recommend that overweight and obese
individuals lower their current level of energy intake by 500–1,000 kcal per day combined with a
reduction in dietary fat intake to < 30% of total energy intake. Furthermore, these individuals are
recommended to progressively increase their level of physical activity to a minimum of 150 minutes
(30 minutes, 5 times per week) of moderate-intensity exercise. For long-term weight loss, the guide-
lines suggest an eventual increase to higher amounts of exercise (e.g., 200–300 minutes per week or
approximately 2,000 kcal per week of leisure-time physical activity). However, this goal might not
be realistic for obese patients just beginning a weight loss program. Obese patients should begin a
program slowly, building to moderate levels of activity (e.g., brisk walking) for 30 to 40 minutes,
3 to 5 times a week (an expenditure of 150 to 225 kcal per session) (NHLBI, 1998). The focus of
physical activity should be weight loss where maximum physical exertion is not required. Moder-
ate-intensity lifestyle activity can be as effective as higher intensity exertion in burning calories
(Andersen et al., 1999; Dunn et al., 1999; Foreyt & Pendleton, 2000). Talking with patients about
the benefits of moderate-intensity exercise and encouraging even some modest increases in physical
activity might lead them to value even modest efforts and contribute to overall treatment adherence.
Diet
The USDA guidelines recommend a reduction of 500–1,000 calories per day, which will lead to a
weight loss of 0.45–0.9 kg (1–2 lb) per week (NHLBI, 1998). According to these guidelines, women
should follow a diet of 1,000 to 1,200 kcal per day, and men 1,200 to 1,500 kcal per day (NHLBI,
1998). A reduction of 500 calories per day will result in a loss of one pound per week (Foreyt &
Pendleton, 2000). Determining an appropriate caloric intake, along with self-monitoring, will
enable patients to attain better control over their diet. However, knowing the amount of calories in
a given meal is not easy. When in doubt, patients should focus on portion sizes, especially with
those foods known to be high in fat content (Foreyt & Pendleton, 2000).
In addition to reducing calories, patients should be encouraged to lower the amount of fat and
empty calories they ingest. The Food Guide Pyramid (USDA, 1992) and the Exchange Lists for
Meal Planning (American Dietetic Association and American Diabetes Association, 1989) can be
helpful in determining what foods to eat and the number of servings that promote healthy eating.
By following a balanced, reduced-calorie diet, with choices made according to USDA recommenda-
tions, patients will have more long-term success with weight loss and subsequent management.
Components of Obesity Treatment Strategies

The above treatment strategies can be delivered either individually or in group formats, depending
on the needs of the patient and the facility’s ability to provide the needed services. Currently, most
behavioral programs are delivered in weekly, small-group programs consisting of 10–20 patients
over 20 or more weeks (Wing, 2004). The duration of obesity treatment programs has steadily
increased over the past 30 years from an average of 8.4 weeks in 1974 to an average of 27 weeks by
the mid-1990s (Wing, 2004). This shift has occurred as researchers began to realize that obesity
treatment is a lifelong disease-management process. In addition to traditional individual and group
delivery of obesity treatment, long-term approaches include the use of support groups and promoting
intermittent individual treatments. Several current examples of obesity treatment programs
that follow a lifelong maintenance approach to obesity treatment include the LEARN Program
(Brownell, 2000), Structure House, and the Duke Diet and Fitness Centers programs. It is important
to note that not all these strategies need to be used by a patient, nor is there a particular order in
delivering these approaches. The use of these strategies should be determined on an individual basis
by the physician or in consultation with the rest of the health-care team.
Pharmacotherapy Treatments
Although lifestyle modifications appear to be helpful for most obese patients, they do not ensure
long-term, weight-loss maintenance (Poston & Foreyt, 2000). Without recurrent contact, most or all
of the weight patients lose will be regained within 3 to 5 years (Wing, 2004; Perri & Foreyt, 2004).
Many patients need additional intervention. Current National Institutes of Health clinical guidelines
view pharmacotherapy as an adjunct to lifestyle modification programs (NHLBI, 1998). Pharmaco-
therapy is appropriate for patients with a BMI of 30 or greater or with a BMI of 27 or greater with
other co-morbidities (e.g., hypertension, dyslipidemia, or type 2 diabetes) (NHLBI, 1998).
Researchers comparing the effectiveness of drug treatment alone, behavior therapy alone, and
combined drug treatment and behavior therapy found that behavior therapy alone and the
combined behavior therapy with drug treatment resulted in greater weight loss than a wait-list
control group or the drug alone group (Craighead, Stunkard, & O’Brien, 1981; Stunkard, Craighead,
& O’Brien, 1980). Obesity drugs in conjunction with dietary programs typically result in modest
weight losses compared with placebo groups (NHLBI, 1998). The effects of drug treatments maxi-
mize within the first 6 months of initiation, with weight loss being generally maintained for the
duration of the treatment (Poston & Foreyt, 2000). Table 13.4 lists examples of available obesity
medications.
Noradrenergic Drugs. Noradrenergic drugs affect weight by suppressing a patient’s appetite. Nora-
drenergic drugs include phentermine resin (Ionanmin), mazindol (Sanorex), phenylpropanola-
mine (Dexatrim), phendimetrazine (Plegine), and diethylpropion (Tenuate). When combined with
dietary programs, these medications produce modest, short-term weight losses compared with
placebo. The U.S. Food and Drug Administration (FDA) has not approved any of these drugs for
the long-term treatment (i.e., 1 year) of obesity (Poston & Foreyt, 2000). Side effects of these drugs
can include increased heart rate and blood pressure, insomnia, constipation, and dry mouth
(Yanovski & Yanovski, 2002).
Serotonin and Noradrenaline Reuptake Inhibition. Sibutramine (Meridia) is a serotonin and

noradrenaline reuptake inhibitor. It is approved by the FDA for the long-term treatment of obesity.
Sibutramine was developed initially as an antidepressant (Luque & Rey, 1999). However, weight
loss was seen in depressed patients who were not actively attempting to lose weight (Foreyt &
Pendleton, 2000). Clinical studies have shown that sibutramine produces weight losses of 4.7 to 7.6 kg
(10.3 to 16.7 lb) in patients receiving the drug compared with placebo. The weight losses are dose-
dependent and level off at 6 months (Lean, 1997; Seagle, Bessesen, & Hill, 1998; Bray & Ryan,
TABLE 13.4 List of Obesity Drugs

Agent DEA Schedule Action
Diethylpropion (Tenuate) IV Noradrenergic
Mazindol (Sanorex) IV Noradrenergic
Orlistat* (Xenical) None Lipase Inhibitor
Phendimetrazine (Plegine) III Noradrenergic
Phentermine (Fastin) IV Noradrenergic
Phentermine resin (Ionamin) IV Noradrenergic
Phenylpropanolamine (Dexatrim) Over-the-counter Noradrenergic
Sibutramine* (Meridia) IV SNRI
DEA = Drug Enforcement Agency; SNRI = serotonergic noradrenergic reuptake inhibitor.
*Orlistat and sibutramine are the only drugs labeled by the Food and Drug Administration for long-term treatment of
obesity.
2004). In more than 20 trials weight losses were significantly greater in sibutramine-treated patients
(who lost about 6–10% of body weight over 6–12 months) than in those given the placebo (Foreyt
& Pendleton, 2000). Sibutramine also has been studied in a number of unique populations includ-
ing obese controlled hypotencives, diabetics, and ethnic minorities further establishing its effective-
ness (Poston & Foreyt, 2004).
Side effects of sibutramine include a mean increase in blood pressure of 1–3 mm Hg as well as a
mean increase in heart rate of about 4 bpm (Lean, 1997). A few patients experience a significant
increase in blood pressure, so blood pressure needs to be monitored (Lean, 1997). These potentially
clinically significant increases have been documented with an incidence of 2% relative to placebo in
patients with uncomplicated obesity (Foreyt & Pendleton, 2000). Care should be used when
prescribing sibutramine in patients with a history of hypertension, and it should not be given to
those with uncontrolled or poorly controlled blood pressure. There have been no reported cases of
ischemic coronary problems, arrhythmias, cerebrovascular difficulties, neurotoxicity, primary
pulmonary hypertension, or valvular heart disease with patients taking sibutramine compared with
placebo (Bray & Ryan, 2004; Foreyt & Pendleton, 2000; Lean, 1997). There are drug interactions
with monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs),
erythromycin, and ketoconazole (Foreyt & Pendleton, 2000).
Lipase Inhibition. Orlistat (Xenical) is a lipase inhibitor that works by reducing the body’s absorp-
tion of dietary fat. It is a nonsystemic drug that blocks about 30% of dietary fat (Hvizdos &
Markham, 1999; Van Gaal & Bray, 2004). Orlistat has been approved by the FDA for long-term use.
One clinical study reported weight losses of about 5 kg (11 lb) after 12 weeks of treatment with orl-
istat (360 mg per day) compared with 2-to-3-kg losses (4.4 to 6.6 lb) in the placebo group (Drent
et al., 1995). The weight losses appeared to be dose-dependent, with lower doses producing smaller
weight losses. Another study found that patients given orlistat over a 2-year period experienced
substantial improvements in weight and other health parameters (e.g., improvements in low-
density lipoprotein [LDL] cholesterol and insulin) compared with the placebo group (Davidson
et al., 1999). A number of 2-year, randomized, double-blind prospective studies have found that
patients lose significantly more weight with orlistat than placebo and improve their health profiles
(Foreyt & Pendleton, 2000). Recent findings suggest that adding Orlistat to lifestyle-change
programs provides an added benefit of lowering the incidence of type 2 diabetes in obese patients
with a risk reduction of 37.3% over a four year period (Torgerson & Boldrin, Hamptman, & Sjos-
trom, 2004).
The contraindications for the use of orlistat include chronic malabsorption syndrome or
cholestasis (Foreyt & Pendleton, 2000). Side effects include changes in bowel habits, such as oily
or loose stools, the need to have a bowel movement quickly, bloating, or oily spotting. These side
effects tend to occur when individuals consume more than 30% of calories from fat. They can be
minimized once patients lower the fat in their diet to less than 30%. Orlistat reduces the absorption
of fat-soluble vitamins A, D, E, and K as well as beta-carotene. Patients taking orlistat should take a
multivitamin supplement containing fat-soluble vitamins (Foreyt & Pendleton, 2000).
Surgery
Past surgical treatments for obesity have included wiring the patient’s jaw to lower caloric intake
and jejunoileal bypass to induce malabsorption. However, both these treatments were abandoned
because of lack of long-term efficacy (jaw wiring) or unacceptable side effects (jejunoileal bypass)
(Gray, 1999). Currently, gastric partitioning is used to decrease the intake of food by increasing sati-
ety through decreasing the size of the patient’s stomach. The current NIH guidelines for surgical
interventions indicate that this option is only acceptable for carefully selected patients with clinically
severe obesity (BMIs of 40 or greater or BMIs of 35 or greater with co-morbid conditions) when less-
intensive techniques have not worked and the patients are at high risk for obesity-related morbidity
and mortality (NHLBI, 1998).
Severely obese patients have traditionally not been helped by the more conservative interven-
tions such as lifestyle modification (Foreyt & Pendleton, 2000). The surgical option is seen as a
reasonable approach for severely obese patients who are at increased risk for premature death
and whose potential benefits from the procedure outweigh the involved risks (National Institute
of Health Consensus Development Conference Statement, 1992; Sjostrom, 2004). The effectiveness
of surgical interventions has been well documented, with weight losses of 100 lb or more after 12
months following surgery (Foreyt & Pendleton, 2000; Sjostrom, 2004).
Treatment Guidelines
Traditionally, the choice of obesity treatment has been based primarily on the amount of excess
body weight (Hill, 1998), with the more aggressive therapies targeted toward patients who are more
obese or who have more health complications (Anderson & Wadden, 1999). Interventions for
overweight patients (BMIs of 25 to 29.9) have typically focused on lifestyle modification strategies.
Treatments for obese patients (BMIs of 30 to 39.9) usually require more aggressive options such as
pharmacological treatments, very low-calorie diets, or residential programs. Those who are severely
obese (BMIs of 40 or greater) may need gastric bypass surgery (Anderson & Wadden, 1999; Hill,
1998; NHLBI, 1998). The NIH has created a treatment algorithm for the evaluation of overweight
or obese individuals (see Figure 13.2) (NHLBI, 1998).
The initial decision is based on BMI. Additional steps consist of evaluations of related factors,
including individual history, physical examination, laboratory tests, and motivation to lose weight.
These steps help determine the type, frequency, and level of weight loss strategies the patient should
attempt (NHLBI, 1998).
In addition to the NIH clinical guidelines, Hill (1998) has proposed three general models of
obesity management based on the extent to which primary care providers are willing and able to be
involved in the chronic management of their obese patients. The minimal model involves the
assessment of risk followed by referral of those with high risk to more comprehensive obesity
programs. The intermediate model consists of the primary care providers evaluating risk; establish-
ing treatment goals; providing information concerning lifestyle modification strategies, pharmacother-
apy, and reduced calorie diets; and evaluating treatment outcomes. The third model includes all
Treatment Algorithm*
1
Patient encounter
2
Hx of ≥ 25 BMI?
No
Yes
3 BMI
measured in past
2 years?
4 6
BMI ≥ 30 OR
• Measure weight, 5 BMI ≥ 25 OR 7 {[BMI 25 to 29.9
height, and waist waist circumference Yes Yes
Assess risk factors OR waist circumference ≥ 88
circumference > 88 cm (F) 8
cm(F) ≥ 102 cm(M)]
• Calculate BMI > 102 cm (M) AND ≥ 2 risk Clinician and patient
factors} devise goals and
treatment strategy for
No
weight loss and risk
factor control
14 12 Does
Yes Yes
Hx BMI ≥ 25 ? patient want to
lose weight?
9 Progress
Yes
No No being made/goal
15 13 achieved?
Brief reinforcement/ Advise to maintain
educate on weight weight/address No
management other risk factors
16 11 10
Periodic weight Maintenance counseling Assess reasons for

check • Dietary therapy failure to lose weight
• Behavior therapy
Examination
• Physical activity
Treatment
* This algorithm applies only to the assessment for overweight and obesity and subsequent decisions based on that assessment. It does not reflect any initial
overall assessment for other conditions and diseases that the physician may wish to do.
Fig. 13.2 NIH obesity treatment algorithm (from NHLBI, 1998).
aspects of the intermediate model but additionally emphasizes long-term maintenance of reduced
body weight (Hill, 1998).
Role of the Behavioral Health-Care Specialist in Obesity Treatment

In some instances, physicians consult with behavioral health-care specialists (BHS) to aid them in
obesity treatment. The BHS functions as an integral part of the patient’s multidisciplinary team
by providing additional support and training in how to most effectively implement lifestyle modifi-
cations and maintain them over time (Foreyt & Poston, 1998). The BHS can aid the physician, the
multidisciplinary health-care team, and the patient with strategies for implementing and maintaining
the obesity treatment strategies. Additionally, the BHS can act as a research consultant in determining
more effective and efficacious treatments for obesity. Discussions between the physician and BHS
can occur at multidisciplinary meetings, case conferences, individual rounds, and through medical
charts. Information pertaining to treatment progress and recommendations are typically shared
during these various discussions.
Review of Obesity Prevention

Prevention includes the primary prevention of obesity itself, secondary prevention or avoidance of
weight regain following weight loss, and prevention of further weight increases in obese patients unable
to lose weight (Jeffery, 1998; National Task Force on Prevention and Treatment of Obesity, 1994). Most
strategies for the prevention of obesity have focused on modifying the obese patient’s behaviors
(predominantly diet and physical activity). However, they have provided little in the way of actual pro-
cedures or guidelines for prevention (Nestle & Jacobson, 2000) and have not been very effective.
Primary prevention of obesity should include strategies that focus on the environmental influences
that affect obesity. These influences include food marketing practices, media and advertising, trans-
portation patterns, community organization, and lack of opportunities for physical activity during
the workday (French, Story, & Jeffery, 2001; James, 1995; Jeffery, 1991; Poston & Foreyt, 1999).
Creating policies and procedures that promote healthy eating and increased physical activity will
enhance the promotion of weight loss and reduction in the prevalence of obesity. Obesity
prevention needs to be recognized by both the government and health-care payers (HMOs and PPOs).
Primary care providers can play an important role in obesity prevention because of the high
proportion of overweight and obese patients who come for treatment in the primary care setting.
Primary care providers have a significant role in preventing obesity and its related medical disor-
ders through control of dyslipidemia, high blood pressure, and type 2 diabetes (NHLBI, 1998).
Because children and adolescents visit primary care settings frequently as they grow, primary care
providers can play an integral part in the prevention of childhood obesity by educating and treating
the early signs of overweight.
Summary
Obesity is a complex chronic disease that requires long-term management similar to other chronic
medical disorders (e.g., hypertension or type 2 diabetes). Current treatment guidelines suggest that
lifestyle interventions utilizing behavior modification principles (e.g., goal-setting, self-monitoring,
etc.) are helpful for many patients, particularly those with BMI less than 30. Patients with severe
obesity or with obesity-related, co-morbid conditions (e.g., hypertension, heart disease, type 2
diabetes) may benefit from adjunctive pharmacotherapies or obesity surgery in extreme cases.
Mental health professionals can assist in the interdisciplinary treatment of obesity by providing
primary care physicians with training in the use of behavior modification strategies and by assisting
in the assessment and triaging of patients into appropriate treatments.
Acknowledgment
This work was partially supported by a grant from the National Institutes of Health (NIDDK
DK58299).
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Chapter 14
As Precise as the Scalpel’s Cut … Sort of:
Psychological and Self-Regulation
Treatments in Preparation for Surgery and
Invasive Medical Procedures
RODGER S. KESSLER
There is a compelling argument in support of psychological preparation for surgery, supported

by 40 years of clinical and research literature. Such efforts have been demonstrated as effective in
improving medical outcomes as well as saving health-care resources. Despite this, psychological
preparation for surgery is not widely used. In addition to the observation that most psychological
interventions in medicine are underused, there are particular dilemmas, having to do with lack of
financial incentives, the difficulty of adding another process to the tight time frame in the surgical
suite, and the fact that surgery, as a complex psychological and emotional experience, frequently
needs to be psychologically responded to, but currently is not a part of the theme of surgery.
In addition to a surgery problem, psychological attention to upcoming surgery is clearly a primary
care problem. Primary care is the place where high utilizers of medical services will present pre- and
postsurgical problems. Also, patients who have had a poor history with surgical experiences or who
are specifically stressed by an upcoming procedure will present these issues in primary care.
After reviewing these issues, this chapter will present an intervention model based on the
research of the past 40 years. Hallmarks of the intervention include self-efficacy, face-to-face
contact, assessment of individual differences, psychoeducation, and tailored intervention. The steps
of the procedure, including strategies for selecting treatment options, are then elaborated.
More than 40 years ago, Janis (1958) first theorized that patients receiving preoperative informa-
tion about their upcoming surgery would generate “the work of worry,” reduce anxiety, and facilitate
recovery. Egbert, Battit, and Turndorf (1963) demonstrated that providing a presurgical visit the
night before surgery would reduce anxiety and improve recovery. Both of these observations
continue to inform contemporary practice. However, strategies that enhance patients’ beliefs in
their ability to successfully cope with the demands of surgery appear to have the most robust
support (Kessler & Dane, 1996; Van Dalfsen & Syrjala, 1990) and have influenced most contemporary
applications. Evidence suggests that contemporary surgical preparation can be defined as a face-to-face
273
assessment of individual differences, followed by a brief, tailored intervention delivered in vivo

using some combination of procedural and sensory information and training in coping strategies,
combined with surgery-specific suggestions for enhanced function and recovery (Kessler &
Dane, 1996).
Increasingly, providing the best clinical care to surgery patients in the least amount of time is a
key requisite of surgical care. In some areas of surgery and technology the level of surgical skill has
improved outcomes to the extent that minimal improvement in postoperative return to function is
expected (e.g., laparoscopic cholecystectomy). In other aspects of return to function, recovery
is greatly affected by the patient’s response to the surgical intervention (Kessler & Whalen, 1999).
The above observations are not surprising if one is familiar with the clinical and research literature
in the area of surgical preparation. Psychology, nursing, and anesthesiology have researched prepa-
ration for surgery for over 40 years (Kessler & Dane, 1996). There have been numerous findings
concluding that preparation for surgery has demonstrated effectiveness in assisting patient func-
tioning pre-, intra-, and postsurgically, improved rates of return to function, and saved health-care
resources (Arthur, Daniels, McKelvie, Hirsch, & Rush 2000; Blankenfield, 1991; Johnston & Vogele,
1993; Mumford, Schlessinger, & Glass, 1982; Rogers & Reich, 1986). Strategies used in these
preparations have ranged from procedural and sensory information provision, coping skills training,
brief cognitive and behavioral treatments for anxiety, relaxation training, imagery, suggestion, and
hypnosis. Most contemporary research in the area has used some combination of these interventions.
Preparation as an Empirically Supported Treatment

Chambless and Hollon (1998) have developed what appears to be the most widely used criterion
for empirical support applied to psychological treatments. They suggest that empirically supported
therapies (ESTs) can be used to describe treatments that have been shown to be efficacious in
controlled research with specific populations. The literature on surgery preparation demonstrates
that surgical preparation meets the designation as an EST.
There have been at least four meta-analyses of the surgical preparation literature that support
designation as an empirically supported treatment. In the initial review Mumford, Schlessinger, and
Glass (1982) concluded that of 34 controlled outcome studies, covering approximately 2,000
patients, patients receiving preparation for surgery physically recovered more quickly, felt better
psychologically, and had a 2.4-day shorter hospital stay than those who did not. Rogers and Reich
(1986) noted that the evidence was compelling that both for surgery and obstetrics preparation had
a significant effect clinically and economically. Blankenfield (1991) reviewed 18 studies that used
hypnotic suggestion or relaxation to prepare patients for surgery. He found that 16 of the 18 studies
supported the effectiveness of the intervention in accelerating postoperative function. He also
observed that among the dimensions affected by surgical preparation, seven studies demonstrated
shortened hospital stay, seven studies demonstrated less postoperative narcotic use, five studies
demonstrated lower postoperative pain, six studies demonstrated lower postoperative anxiety, two
studies demonstrated less blood loss, and three studies demonstrated earlier return of gastrointestinal
function. Johnston and Vogele (1993) reviewed 38 studies and concluded that there is substantial
agreement that psychological preparation for surgery offers substantial clinical and cost benefit.
The meta-analysis conducted by Chiles, Lambert, and Hatch (1999) of the effect of psychological
interventions on medical cost offset concluded that the most dramatic treatment effects were
for the behavioral medicine treatments of surgical inpatients, resulting in significant decrease
in length of stay and an increase in psychological well-being. They further concluded that the great-
est demonstration of effect was in the area of providing psychoeducational intervention to assist
hospitalized surgical patients.
As Precise as the Scalpel’s Cut … Sort of • 275
The number of studies quantifying cost savings is limited, but compelling. In the Mumford et al.
(1982) analysis of approximately 2,000 intervention and control patients, it was found that for the
intervention group, there was a 2.4-day reduction in hospitalization compared with patients who
did not receive intervention. In 1991, Rapkin, Straubing, and Holroyd compared hypnotic prepara-
tion with the usual preparation in head and neck surgery. In addition to significant clinical out-
comes, the hypnotic preparation group had a 5-day shorter postoperative stay and an average
reduction in hospitalization costs of $6,725 per hospitalization. In 1993, Disbrow, Bennett, and
Owings reported on their study of return of gastrointestinal ileus. A post hoc analysis of the data
showed a 1.5-day reduction in hospitalization in favor of the preparation group, with a per surgery
savings of $1,200, in addition to the clinical outcomes. Bennett remarked that when one of his col-
leagues approached him with a request to analyze the cost data post hoc, he initially questioned the
idea. His reasoning was that in the period of time since the Mumford et al. analysis, much had
changed in hospitals, people were discharged earlier, and the Mumford findings would not stand up
to contemporary hospital economics. He eventually consented to the analysis that produced these
findings (H. Bennett, personal communication, 1995). Recently Lang and Rosen (2002) demon-
strated that hypnosis in combination with sedation reduces the cost of interventional radiologic
procedures by more than half compared with the cost of the procedure with standard sedation.
Taken together, the data have been sufficiently compelling to lead Johnson and Vogele (1993) to
observe that a large number of nonsignificant findings would have to exist to challenge the signifi-
cance of findings of benefit.
In reviewing the surgical preparation literature, the majority studied surgeries that require
hospitalization for one or more nights. Recently, Lang, Benotsch, and Fick (2000) reported on a
study of patients receiving interventional radiology procedures, some of whom were ambulatory.
The study randomized 241 patients to standard medical treatment, structured attention, or self-
hypnotic relaxation with structured attention. Results demonstrated that in the relaxation prepara-
tion condition there was less analgesia used, procedural duration was shorter, there was no increase
in pain scores, and there were fewer patients with hemodynamic instability.
Preparation Is Not Widely Used

Despite such a lengthy history, clinical and research literature, publications in the most widely read
medical journals, demonstrated health-care savings, and specificity of procedures that define this
area of psychological intervention in medicine, use of such preparatory strategies is limited outside
of experimental situations. This appears particularly accurate in nontertiary medical care. There are
a number of reasons that might explain this.
At this point of development, psychological interventions are not well known within medicine.
Psychological professionals and their services are still establishing a foothold and validity in medical
settings. Efforts to integrate psychology and medicine are encouraging, but their acceptance and
integration in general medicine is still far off. Also, psychological aspects of medicine are still
lumped within the generic mental health system, which is seen as difficult to access and a black hole
into which patients may or may not flow, and the content and results of which are essentially
unknown (Gray, Brody, & Hart, 2000).
This is an era where the field of medicine is struggling with pressure to be evidence based and is
often overwhelmed with the amount of available evidence. Clinical pathways and evidence-based
treatments may be well developed, but in many areas the sheer overwhelmingness of contemporary
medical practice is a barrier or a limitation to their implementation. The result is treatments that
often have limited evidence to support their use or motivation to change practice. This leaves
psychological treatments—and most certainly psychological treatments in surgery—with no easy

platform from which to offer or implement its evidence.
As has been observed elsewhere in this volume, in fee-for-service environments there are no
financial incentives to consider the utility of integrated treatment strategies. Even in capitated
models I am not aware of any system that has regularly used psychological interventions in surgery
to enhance clinical outcomes and cost efficiencies. In the carve-out models, which have become the
norm for managing psychological treatments, there is a disincentive to consider the psychological
issues in medicine, even though primary care has been dubbed the de facto mental health system
(Regier et al., 1993). Since penetration rates and the strategies employed by managed care to limit
access to mental health services are based on their estimates of community utilization, they are
certainly not motivated to pursue strategies that increase penetration and thus utilization.
It should be clear that attending to psychological issues in surgery does not currently fit either
the theoretical or practical dimensions of surgery practice. Primary care views surgery as something
to refer out to specialty care (surgeons) to evaluate, manage, and (hopefully) resolve. Surgery is
seen as a primarily technical problem where a part of the body (e.g., leg, back, etc.) or organ (heart,
lung, etc.) has a problem, is isolated, worked on, and the issue resolved as best it can be. That
surgery is a complex psychological and emotional experience requiring specific attention as part of
the surgical process has not been historically viewed as a primary focus of care. Even the most
minimalist additional psychological intervention is experienced as a perturbation to a system that
has not discerned that a problem exists and as such is neither aware of nor interested in resolving
that which is not perceived as a problem. Also the referral from primary care to surgical evaluation
and through surgery is a well-orchestrated flow, with few easy opportunities for significant changes
in that flow.
Why Does Surgical Preparation Work?

When we practice psychological medicine, we are constantly reminded to practice as medicine
does. Medical interventions are mostly brief and specific. Surgical preparations are brief and
specific. In my clinical practice, the most frequent number of patient contacts for a preparation is
one. In less than 20% of cases there are two, and rarely more than that. In an often-cited study of
reducing the postsurgical time until return of bowel function, Disbrow et al. (1993) used an
instructional intervention that was less than 20 minutes in length. Lang and Rosen’s (2002) intra-
procedural hypnotic intervention occurred once, during the procedure, and yet increased the rate
of hemodynamic stability in invasive radiology procedures. In the Chiles et al. (1999) meta-analysis
there was support for the idea that specificity of the type of intervention affects outcome. They
found that psychoeducational interventions have significantly higher effect sizes than psychothera-
peutic interventions. Similar findings characterize the surgical preparation literature. It has been
observed that activating cognitive coping strategies is a core component in successful preparation
(Kessler, 1997; Salmon, 1994). Additionally, surgical preparation appears to be effective because it
can be equated to capturing the Holy Grail—demonstrating that psychological interventions can
affect physiological and biochemical processes.
It is well established that the stress response to an upcoming surgical event is a complex
neuroendocrine affector-effector response elicited by a large number of exogenous and endogenous
stimuli (Kessler & Whalen, 1999), including fear, anxiety, and pain response in addition to surgical
trauma, infection, and exogenous drugs. There have been consistent reports of preparation being
associated with lowered anxiety, lowered pain, and less use of analgesic drugs (Evans & Richardson,
1991; Evans & Stanley, 1991; Syrjala, Cummings, & Donaldson, 1992). In addition, there have been
findings that support the role of psychological preparation in decreased serum cortisol levels and
more rapid wound healing (Holden-Lund, 1988), diminished blood loss at the surgical site
(Bennett, Benson, & Kuiken, 1986; Enqvist, von Konow, & Bystedt, 1995), rapid return of
gastrointestinal motility (Disbrow et al., 1993), and increased vital capacity and pulmonary func-
tioning (Hathaway, 1986). Montgomery, Weltz, and Bovbjerg (2002) have recently broadened the
scope of these findings to excisional breast biopsy patients, with their finding that a 10-minute hyp-
notic procedure administered on the day of surgery reduced both postsurgical pain and distress.
The Suggestibility of Critical Moments

Psychologically, patients accurately view surgery as a critical event, independent of the severity of
the procedure (Kessler & Whalen, 1999). Early on, Egbert et al. (1963) demonstrated that establish-
ing a helping relationship with a patient before surgery contributed to patient readiness, tolerance
of, and recovery from surgery. Dabney Ewing (1986), a surgeon who works with severe industrial
burn patients, has observed that during acute, serious medical conditions patients are universally
advanced in their ability to be receptive to instruction and suggestion. Such openness to instruction
and suggestion has been observed to be a function of hypnotic susceptibility in some settings
(Kirsch, 1997), the response to reasonably presented realistic instructions (Barber, 1984), or the
logical consequence of the interaction of characteristic coping style with a caregiver response that is
tailored to that coping style (Kessler, Dane, & Galper, 2002).
Patients often have heightened autonomic arousal and distorted and catastrophic cognitive styles
prior to surgery. The focus of information and cognitive coping-based preparation strategies assists
in the creation of a focused sense of order. It reframes the amorphous set of surgical experiences
into a set of discreet steps that enable focus and attention on activities designed to enhance successful
participation in and recovery from the surgical process. In this way, surgical preparation resembles
the kind of self-efficacy training offered by Bandura (1986), who found self-efficacy to be learning
successful strategies and engaging in them, with those successes generalizing to an overall view of
confidence and success. In surgery preparation, training for self-efficacy prior to the event and the
actual occurrence of the event are closely tied in time, allowing the recency of the cognitive, behav-
ioral, and physiological self-regulation of the preparation to generalize the surgical event.
A patient came to see me who was preparing to have both knees surgically replaced. She came
fearful about the procedure and because she did not understand what was going to happen to her.
When asked to describe what she really wanted to happen she replied “I wish that the first one was
already done so I could know everything that happened. You know, the first thing then the second
thing and so on. Then I would feel better because I would know what was to happen.” We used a
rehearsal strategy as preparation, going through as many steps as possible for her to be able to
anchor her experience.
Surgery as a Primary Care Problem

For the purposes of this discussion, primary care is defined as (1) the office within which primary
care physicians practice and (2) the local specialty care medical/hospital services the primary care
physician accesses in the routine care of patients. Therefore, psychosocial concerns generated by
medical events that occur outside of the primary care office, such as surgery, are still primary care
issues. Increased psychosocial reactivity is certainly frequently part of patient reaction to surgery,
particularly those for whom stress reactivity due to life occurrences activates medical utilization.
Three subsets of patients are likely to look to primary care for guidance and support as they prepare
for upcoming surgeries: high utilizers of medical services, patients with previous negative medical
and surgical experiences, and patients for whom an upcoming surgery is a particularly stressful or
threatening experience.
The top 10% of utilizers of medical services account for more activity than the lowest 50% of
utilizers of a practice (Katon et al., 1990). It also has been demonstrated that about 50% of high
utilizers have psychiatric co-morbidities (Katon et al., 1990). I am not aware of data specifying
differences in surgery rates for high medical utilizers. It stands to follow, however, that patients who
are psychiatrically co-morbid and who use medical services to support psychosocial distress are
likely both to be consumers of surgeries and to have increased difficulty both preparing for and
recovering from surgery, with increased service demand from primary care.
A primary care physician and her surgeon referred a woman to me. The surgeon refused to
operate until I felt the patient could successfully undergo a colostomy closure. She had a lengthy
history of invasive procedures, accompanied by lengthy hospitals stays in excess of what was
predicted, difficulty discontinuing postsurgery narcotics, which became a management problem for
the primary care physician, and the patient was labeled as being difficult to deal with. I saw the
patient three times, supported her to discharge affect, helped her problem solve about her children
and how to heat her house in Vermont winter while she was in the hospital, and used very good
imaginative skills to teach her dissociative imagery with imaginal review of a successful experience.
The previous sequalae never occurred during the hospitalization or upon follow-up by the primary
care physician.
It seems equally clear that among the primary care patient population there are those who have
had previous negative medical surgical experiences. As will be discussed shortly, patients with these
experiences have a greater likelihood of repeated difficulties with current surgeries (Kessler & Dane,
1996), have greater rates of complications, and have longer postoperative stays (Kessler & Whalen,
1999). Also, patients with early pain histories or who have grown up in families with medically
related pain histories are likely to experience greater adult pain and to cope more poorly with
medical and surgical events (Bachiocco, Scesi, Morselli, & Carli 1993; Lester, Lefebre, & Keefe, 1994).
An obstetrician referred a woman for assistance prior to her first delivery. She had poor toler-
ance of any medical care and had a needle phobia. The needle phobia was easily desensitized, and
during the interview, a number of poor experiences with pediatric medicine were revealed, includ-
ing her mother’s observation about the pain that was suffered during the patient’s childbirth. The
guilt and embarrassment of these two early experiences had never been revealed, and after that
discussion and related emotion, the patient quickly learned imagery-base relaxation for needle
insertion and had a successful childbirth.
It is equally important to identify any patients with unremarkable psychological histories who
view and respond to upcoming surgery as a major and significant psychological event that they are
not sure how to cope with. Lack of clarity about seriousness of the surgery or its consequences,
confronting real or catastrophic potential mortality, logistics, and expenses may each or in combi-
nation be sufficient to generate levels of reactivity that may become the focus of a primary care
visit. Such visits may be regular, scheduled visits for a presurgical history and physical, or for some
other surgery-related concern that masks the psychosocial distress. So, it is clear that primary care is
often involved in assisting psychosocial adaptation to surgery, particularly for certain at-risk
subpopulations of patients.
A man was referred for orthopedic arm surgery. Intellectually he had no problems with the
upcoming procedure, but was left with a sense of anticipatory dread. In our single contact he was
able to identify fear of having a heart attack on the table. He explained that his father had gone to
the hospital for a routine procedure and had had a heart attack and died while in the hospital some
3 years prior. He realized that his own fear related to the fear that the same thing would happen to
him, despite his overall good health. After that realization the dread diminished and there were no
further complications.
Poor presurgical adaptation or postsurgical hospital adaptation is often associated with

problematic consequences posthospitalization (Rogers, Liang, Poss, & Cullen, 1982). Although the
surgeon attends to some of these consequences, it is often the primary care physician who is called
upon by the postsurgical patient for further management. Patient expectations of postsurgical
recovery and functioning vary, and may or may not match the expected medical course. Energy,
strength, pain, concentration, attention, or medication issues may prompt primary care physician
consultation, and psychological issues surrounding adaptation and recovery often need to be
addressed, particularly if these issues were not satisfactorily responded to presurgically. So patient
psychological functioning before and after surgery is a primary care issue, whether or not it is
specifically the focus of primary medical care.
A man had a hip replaced, which resulted in a prolonged, difficult rehabilitation. He began the
use of antianxiety medication prescribed by his primary care physician and continued its use for a
number of years postrecovery. His physician asked him to see me because of concerns about
ongoing use of the medication. He was seen for almost 5 months. The patient was able to identify
that the hip replacement gave him a message about his aging and eventual mortality, which he
feared. He was not one who could talk of such things with his physician, nor did he discuss the
matter with his family. He understood that the medication was not helping him and agreed to talk
to me because he wanted to eliminate the medication. The ensuing months were spent helping him
confront his aging as well as adapting strategies that would allow him to focus on successful living.
So we are left with empirically supported interventions to specific patients with specified clinical
presentations who can benefit from the service, and a setting that is in the best position to identify
patient need for the service. The next task is to identify the components of the intervention and the
steps necessary to reengineer current primary care practice to accommodate it.
Developing the Intervention: The Steps of the Process

The research literature has not generated sufficient data to allow us to comparatively evaluate
different intervention models. We are therefore left to construct models based on different empirical
findings that, taken together, can be viewed as empirically formulated models, but not yet compar-
atively evaluated. The intervention model proposed here is based on the following set of empirical
findings concerning the best outcomes for surgical preparation:
1. Self-efficacy promotion via active coping strategies enhances the outcomes of surgical prepara-
tion (Salmon, 1994).
2. A face-to-face intervention delivered preoperatively is probably more effective than either a
taped intervention or an intervention delivered intraoperatively (Enqvist, von Konow, &
Bystedt, 1995).
3. An assessment of specified individual differences optimizes the ability to select the most
effective intervention strategy (Kessler & Dane, 1996).
4. Greatest effects are associated with a psychoeducational focus to intervention, including
procedural and sensory information (Chiles et al., 2000, Salmon, 1994).
5. A brief and tailored intervention based on variation in individual differences promoting
effective and successful coping appears to be more effective than a standardized intervention
(Syrjala et al., 1992; H. Bennett, personal communication, 1995).
Rapid Self-Efficacy Promotion Is the Key

Patients distressed by upcoming surgeries have been characterized as having high levels of distorted
cognitions and beliefs that exceed probable expectations (Blacher, 1987a). The product of this is
limited effectiveness in coping with the demands of the upcoming procedure. Therefore, no matter
the strategy employed, it may be said that the goal of preparation for surgery is to train, practice,
and implement effective management of the time before, during, and after hospitalization to effec-
tively manage the issues that are distressing during those times. Such a goal not only defines the
tasks of the preparation but also helps physicians identify patients who can benefit most from a
preparation procedure. The research literature does not adequately inform us how to identify
patients who will benefit as opposed to those who will not. Preoperative psychological state has not
been found to be a useful predictor of surgical outcome or preparation effectiveness (Salmon,
1994), so we are left with clinical observation to determine selection strategy. Certainly patients
whose ability to tolerate surgery is negatively affected because of psychological functioning should
be candidates. This can range from anxiety about survival, phobias of insertion of IVs, or emotional
volatility that does not appear to have a clear antecedent. Patients who have had previously
compromised or negative surgical or anesthesiology experiences are also particularly deserving of
attention. Also, as with other aspects of medical psychology, patients with limited coping capacities
or support systems might be considered. It is left to further research to give us clearer parameters to
assist in patient selection.
Depending on the method employed, the task is to promote adaptive health behavior based on
the demands of the situation (Auerbach, 1989). Such adaptive coping is a patient-initiated process
of attaching strategies that the patient feels have a good probability of being helpful to desirable
cognitive, physiological, and emotional states. With the ability to accomplish this, patients feel
empowered to use an effective coping strategy in an identified situation, which relates to successful
coping with the upcoming procedure. Such a procedure is solution-focused rather than problem-
focused, with attention focused on successful future outcomes rather than present or past problems
(Kessler & Miller, 1995). The desired treatment outcome is a presurgery focus on the future success
of the surgery and recovery, and a patient’s belief in and active use of efficacious strategies to create
that success. The next sections discuss the steps of that process.
Getting Them There

Surgical preparation is a very portable procedure. It typically requires only one or two visits, each
lasting as short as 30 minutes (Bennett, 1993) to 1 hour (Kessler & Dane, 1996). I have done prepa-
rations in an office within the hospital, in my clinical office, in the emergency room, and in the
preoperative cubicle in the OR suite. Timing of intervention tends to be determined by when a
physician determines a need and the length of time until surgery. I have seen patients a week before
surgery or just the day of surgery. Complexity of the psychological presentation is a determinant of
what appears to be optimal timing. In a complex presentation, 5–7 days prior to surgery seems to
be optimal, because it allows for the scheduling of a follow-up before the surgery. If acuity appears
more manageable, then seeing a patient around 3 days prior to the surgery appears to be optimal.
Promoting a Rapid Story: Framing What Is to Be Resolved

Often, patients present generalized anxieties or concerns about surgery. This is an example of the
state of anxiety (Spielberger, Gorsuch, & Lushene, 1970) that has often been found to accompany
surgery (Salmon, 1994). But this is a trap. A treatment focused on the generalized picture defocuses
both patient and treatment from the story of the surgery. Given the rapid time frame for prepara-
tion, it is critical to quickly identify the specific history, incidents, or perceptions about the surgery
that are stimulating the generalized arousal. Examples might be family pain history, a difficult pediatric
hospitalization, or a bad experience with anesthesia. In my clinical experience of over 10 years in
this area, virtually every patient seen for surgical preparation has been able to identify specific
antecedents to his or her anxiety. The framing of the telling of the story about the antecedent is
always asking the patient to “Tell me about your surgery/procedure.” This enables a patient to
identify the issues that have become the focus for the brief intervention. It is told within the context
of the clinicians needing specific assessment data from which to tailor an intervention. This infor-
mation focuses on assessing previous medical history, primary coping focus, and suggestibility.
Assessing Previous Medical History, Coping Focus, and Suggestibility

Although it is important to support the telling of the story, this task establishes the nature of the
disruption and elicits information the literature suggests is keenly important in constructing the
intervention. Previous medical history is a predictor of functioning before, during, and after the
surgery or procedure (Kessler & Dane, 1996). There have been multiple reports that negative surgical
experience impacts subsequent functioning and healing (Blacher, 1987b; Rogers & Reich, 1986).
Further, individual pain history has been demonstrated to predict intensity, duration, and onset of
postsurgical pain (Bachiocco et al., 1993).
The patient’s characteristic coping style and how it interacts with the coping demands of the
surgery will also influence how a patient will cope with a surgical experience. Coping “repressors,”
those who cope by denying and avoiding, experience more pain and anxiety if given more informa-
tion presurgically, while coping “sensitizers,” patients who deal best with information and taking
action, improve their rate of surgical recovery when given information (Cohen & Lazarus, 1973).
Paradoxically, if sensitizers’ need for attention and information is not addressed, it has been found
they have the poorest postsurgical recovery (Cohen & Lazarus, 1973). The data reviewed strongly
suggest that preexisting medical and surgical history and predominant coping style must be
assessed. Fortunately, doing so is quite simple. Table 14.1 contains the Medical Surgical Experiences
Rating Scale (Kessler, 1992). The scale helps patients rate to what degree an upcoming surgery is
being influenced by a previous hospitalization, surgery, anesthesia, injection, or other similar expe-
rience. It should be completed as part of the initial intake, and it takes less than a minute.
Although there are many measures of coping style, for the purposes of the brief assessment prep-
aration, simply asking a patient often works really well. Asking the question, “Some people like to
know as much as they can about the upcoming procedure so they can actively participate, and some
people don’t want to know very much at all. Which best describes you?” is often sufficient to elicit
this information. In some situations a surgery may have multiple coping demands that require
TABLE 14.1 The Medical Surgical Experience Rating Scale
To what degree are any of the following affecting your upcoming surgery? (Please circle appropriate number)
not at all a little somewhat very much a lot

a hospitalization 1 2 3 4 5
a surgery 1 2 3 4 5
anesthesia 1 2 3 4 5
getting a needle or injection 1 2 3 4 5
pain during any other medical experience 1 2 3 4 5
another family member’s medical experience 1 2 3 4 5
© Rodger Kessler, Ph.D., 1993.
different coping responses. For a discussion of this infrequent but important issue the reader is
referred to Kessler and Dane (1996) for further elaboration.
Suggestibility may seem an odd construct to be part of this discussion. It is included for two
reasons. The first is that there have been a number of studies observing that higher suggestibility
influences recovery from surgery and the efficacy of presurgical interventions (Disbrow et al. 1993;
Rapkin et al., 1991; Rondi et al., 1993). Although these findings are interesting, by themselves they
are not clinically instructive. However, the second reason for including suggestibility in this discus-
sion relates to selection of clinical strategies for preparation. A patient’s suggestibility has been
demonstrated to be a factor that influences clinical ability to modify the components of a patient’s
experience, or at least the type of strategies that optimize or limit such change (Kessler, Dane, &
Galper, 2002). It has been further observed that treatment responsiveness is an interaction between
this suggestibility factor and the contextually and experientially shaped level of participation in
the experience, which is so crucial to its success (Kessler et al., 2002). Therefore, as part of the
assessment we conduct to develop an optimal clinical strategy, some information about relative
suggestibility is instructive in shaping treatment selection.
From Assessment to Treatment Options: The Logical Consequences Position

As a starting point for selecting treatment options, one should consider the logical consequences
that follow from the assessment data just collected. If one respects the story, assesses previous
medical experiences and predominant coping strategies, and further generates an assessment of
gross level of suggestibility, then much of the treatment progression is laid out (Kessler, 1997). Such
information tells you:
• The overall focus of the intervention.

• Whether the intervention needs to include the distinction between historic medical surgical
experiences and the current upcoming procedure.
• Whether more or less information provision is indicated as part of the intervention.
• Whether an imaginal or dissociative strategy is indicated, or whether a more here-and-
now set of coping strategies is probably going to be helpful.
This matrix is summarized in Table 14.2. Once the general framework is laid out, the next step is
deciding the specifics of the intervention by making key decisions about specific treatment options.
Selecting Treatment Options

Earlier it was identified that a preparation will probably include some combination of information
and self-regulation with the product being usable coping strategies that a patient perceives as assisting
his or her self-efficacy. Because of the resource utilization and scheduling issues inherent in surgical
preparation, there have been multiple efforts to utilize procedures that consume less resources and
time. Unfortunately, these efforts have been at best equivocal and have resulted in the most
frequently reported procedures needing to be face to face and individual, with some possible utility
to an adjunctive tape of the preparation for later review and practice. Since it appears that tailoring
to patient need optimizes interventions, previously prepared tapes or written material appear of
limited utility.
Following from that observation, the issues discussed earlier about coping style outline an
intervention strategy suggesting that the role of information provision be tailored to a patient’s char-
acteristic coping style. This certainly influences clinician selection of a point on the self-regulation
continuum from which to intervene. A key dimension distinguishing self-regulation therapies and
TABLE 14.2 The Logical Consequences of Differences in Previous Medical History, Coping Style, and
Suggestibility in Selecting a Preparation Strategy
Differences Logical Consequences Strategies
Coping Style Avoidant Does not want information; does Distraction; dissociative
not want to actively participate; strategies; empower medical
disempowered; passive professionals; passive
strategies; absorbing
comfortable imagery
Confronting Wants information; wants to Information; future rehearsal;
participate; active involvement active strategies; active self-
regulation; participation
Suggestibility More Rapid; dissociative; rapid Rapid use of hypnotic
relationship development; easily strategies; dissociative
absorbed; high imaginal abilities strategies; use of relationship;
imagery
Less Less absorption; internal locus of Promote internal locus of
control; stepwise learned control; use of self-control;
involvement; less dissociative stepwise learned strategies; less
ability reliance on power of
immediate relationship;
rehearsal; less dissociative and
imaginative strategies
Previous Negative Significant Distorted cognitions; negative Cognitive restructuring;
Medical affect; lack of historic/present affective release; dissociative
Experiences boundaries in time and emotion; distinguishing history from
physiologic hyperarousal present; mind/body self-
regulation
selecting one for the focus of treatment is the degree of active self-involvement that a strategy
requires, as compared with interventions that rely on more imaginal and perhaps dissociative strate-
gies. This continuum is illustrated in Table 14.3.
This clinical decision about selecting self-regulation strategy draws on at least two dimensions of
patient characteristics generated during the assessment phase. When evaluating patient interest
in active participation in treatment, coping sensitizers will probably be more interested in active
involvement, and selection of an active self-regulation strategy is indicated. Conversely, coping
avoiders may well just want the whole thing done, and would be just as happy to have little if any
active involvement, therefore suggesting a more distracting and perhaps dissociative strategy. The
second patient characteristic that will certainly influence selection of a point on the self-regulation
continuum is clinician assessment of suggestibility. If there appears to be a substantial degree of
imaginative ability and a preference to use it, then a point closer to the hypnotic end of the continuum
may be indicated. Wickramsekera (1988) has noted that suggestibility is an important consideration
in selecting the most useful psychophysiological treatment strategies. He notes that patients with
lower suggestibility will do better with the structure and cognitive attentional focus of biofeedback.
Patients with substantial suggestibility will do worse with biofeedback and better with the open-
endedness and cognitive freedom of hypnosis. Once the clinician has selected a self-regulation
focus, he or she is ready to proceed with the tailoring of a preparation strategy.
TABLE 14.3 The Voluntary Self-Regulation Continuum

Relaxation Progressive Muscle Relaxation Autogenics Imagery Hypnosis
Tailoring Treatment as Outcome of Standard Assessment

The above assessment and treatment selection strategies suggest that the research literature
prescribes a set of assessment procedures that generally forms a useful framework for most surgical
preparation activity. However, that does not imply that the treatment delivered to our patients
follows a standardized procedure. There is emerging data that suggest the contrary, that the best
effects are generated from tailoring the intervention to the needs of the patient. Although it has
been insufficiently researched, there appears to be support that tailored, individualized interven-
tions generate superior outcomes to standardized interventions (Enqvist et al., 1995; Syrjala et al.,
1992). Therefore, the product of this effort is usually a brief, somewhat standardized assessment of
specified dimensions, which generates data allowing for a tailored intervention that respects coping
style and medical history and takes advantage of levels of suggestibility that might enhance the
treatment. The goal is for the patient to finish the formal preparation; having told his or her story,
with a different future-focused orientation toward successfully employing identified coping strategies
the patient believes to be efficacious.
How to Prepare Medical Offices

Preparing medical offices is a very difficult area with little mapping to rely on. To review briefly, his-
torically surgical preparation has primarily occurred experimentally, and it is generally not
integrated as usual clinical care anywhere I am aware of, with the exception of a small number of
anesthesiologists’ individual practices around the country. Examples of psychologists being active in
surgical preparation as a regular part of medical practice are even more rare. The steps to involve
physicians and their offices parallel the steps necessary to be successful in any aspect of medical or
hospital practice, with some additions. First, generate credibility. In medical settings credibility
starts with being credentialed as part of the medical staff of the hospital. Currently, in most hospitals
that means becoming part of some variation of the allied health professional staff. That may even
mean finding a physician member of the active staff and having him or her sponsor you and perhaps
serve as your supervising physician. It is probably accurate that more hospitals than not require psy-
chologists to be supervised if they are on staff. If that is what it takes to start, then it must be done.
However, that is only a necessary but not sufficient step to generating credibility. Within the scope of
your privileges, attend medical staff meetings and get on medical staff committees, even if it means 7
A.M. meetings, as it does in my institution. Be present on site and attend continuing education semi-
nars. Get known. If you get referrals from physicians make sure they are pleased. Communicate
regularly and develop strong and positive relationships. Next, know both the psychological and medi-
cal literature and be ready to share it. Being involved in surgical preparation means dealing with a
variety of medical and nursing professionals, including primary care physicians, anesthesiology sur-
geons, and cardiologists. It is important to know the key literature in each of those areas.
Where Does One Start? The Current Condition

The literature and experience suggest that primary care has the most advantageous view of patient
adaptation and coping and is currently the least involved in the process after referring to a surgeon,
once a decision to do surgery is made. In the primary care practice in which I work, of the 82
referrals that were made to me between January 1, 2000, and December 31, 2000, only one
was made specifically for preparation for surgery. In terms of best ability to assess patient need and
willingness, primary care practice offers the greatest opportunity. In terms of current organization
of medicine, primary care physicians have been rarely involved.
Anesthesiology is responsible for much of the research literature on surgical preparation. There
are advantages and disadvantages to approaching these professionals to consider efforts in this area.
The advantages include concern with patient psychological functioning as surgery approaches and
usual contact with a patient before surgery. The disadvantages include the tendency to conduct
brief, snapshot assessments of patient psychosocial need, using no formal assessment system,
having an often inflexible schedule, and lacking the ability to predict that the anesthesiologist who
sees a patient preoperatively will be in the operating room during the procedure. In terms of recog-
nizing need and utility of surgical preparation, anesthesiology may be the most open. Unfortu-
nately, because of the volume and pace of operating rooms and patient flow to and from surgery, it
is not easy to accommodate significant change in routine.
Interestingly, it is surgeons who provide my practice with the greatest number of referrals after
years of involvement in this work. However, when a surgeon does not refer a patient for preparation
it means that physicians who probably know the patient better, and who have been involved in ear-
lier stages of acuity, have not seen a need to involve a patient in surgical preparation. One explana-
tion is that it is the acuity of the visit with the surgeon or the closeness in time with the procedure
that generates the patient reactivity and prompts a surgeon to take action. The dilemma is that by
the time that surgeon is that closely involved, acuity is often higher and time to surgery is usually
quite brief. In addition, surgery training is procedural training, and surgeons probably have the
most limited biopsychosocial view of the process. These factors suggest that there is a greater
advantage to earlier detection and intervention. On the other hand, when a surgeon does refer there
is usually an acute, compelling reason that, unresolved, might affect the occurrence or outcome of
the upcoming procedure.
How to Communicate
The single largest complaint I have heard about behavioral health professionals is that they are
unavailable when needed, and that they do not know how to communicate! To be effective in any
aspect of medicine is to be available and to provide rapid, focused feedback. This advice is particu-
larly relevant when working in surgery, where acuity of need, rapidity of intervention, and feedback
are integral to everyday life. A practice model of someone leaving a message on a telephone answering
machine or voice mail is probably an impediment. My pager number is printed on the staff roster,
and I encourage medical offices to use it. In most cases, I can be interrupted while with patients by
crisis or acute-need pages or calls. Even if my schedule for a day is full, I will make time to see a
patient who a physician feels needs to be seen acutely, and I always find the time to see a patient
prior to surgery. This is not outstanding behavior; rather it is emulating the model in which I want
to participate. After a number of years of this, I have begun to become credible.
Similarly, equal consistency in how one reports back to medical colleagues is critical. Getting
consent from a patient to communicate with a referring physician is a basic tenet of practice.
I have not once encountered a patient who was unwilling to grant a release for that communication.
I have developed a standard preparation feedback document, which takes only a couple of minutes
to complete, and which is delivered back to the referring physician after my intervention is com-
pleted. It is brief, summarizes key presenting issues, what was done as intervention, and includes
recommendations about what the physician might consider doing with the patient, either before
the surgery or as follow-up. That document usually becomes part of the medical record or the phy-
sician file. An example is included in Table 14.4. Most of the time that document is sufficient
communication. On occasion, there is a request for a face-to-face or phone conversation.
TABLE 14.4 Presurgical Preparation Form

Type of surgery:
Surgeon:
Scheduled date of surgery:
Date of preparation:
Summary:
Patient’s primary concerns:
Relevant history:
Description of preparation:
Patient’s response:
Recommended procedure:
Who Comes, Who Doesn’t Come, and Who Should Come

Part of the dilemma in discussing surgical preparation clinically, while commenting from
the research perspective, is that there are certainly obvious differences in the populations included.
For example, to be able to have representative groups in a research sample, certain parameters for
inclusion in that sample need to be established. This might mean age or gender parameters, prior
history of psychopathology, or cutoff scores on a psychological measure. However, this also implies
that research samples may be made up of a more restricted set of patients than a clinical sample in a
primary hospital setting.
One group that appears in the clinical setting but is often not included in research samples is the
psychologically distressed high utilizers of medical services described earlier. Such patients not only
use more primary care and more specialist consultation time, but also have a higher volume of
surgeries than other medical patients. They are often particularly challenging, because their histories
with primary care physicians are often difficult and they will often pose a challenge for consultant
surgeons and anesthesiologists. Such patients may need extra time and attention, make more
requests for presurgical and postsurgical medication, have greater pain complaints, and may
need extended hospital stays and higher frequency of ancillary supports. As in other parts of the
medical system this population appears to be small, but consumes greater resources. Referrals
for psychological assistance with these patients almost always come from the surgeon or anesthesi-
ologist. The primary focus of intervention is actively managing the crises and demands that may be
more frequent.
Clinically, the population that appears most frequently in both the clinical and research litera-
tures are patients with acute co-morbid psychological issues that interfere with the progression
leading up to surgery and the surgery itself. When the surgeon or anesthesiologist sees such a
patient, the co-morbidity makes medical management more difficult. Adherence with preoperative
instruction, need for sedation, greater expression of negative effect, higher levels of acute anxiety,
and concerns about surviving the surgery are among the problems with such patients. Often, there
is negative prior medical surgical history, either personally or with family members, and active
coping is compromised. Focus needs to be on rapid assessment of dimensions identified earlier, and
brief psychological intervention targeted on remediation of distortions generated from previous
medical surgical experience, attention to resolving presenting symptoms, and successful coping
using the primary historic coping strategy as focus.
Another small but interesting clinical population that will sometimes either self-refer to a
psychologist for preparation or make that request through a primary care physician or surgery are
patients whose model of medicine is a mind-body experience. Their self-preparation for the
upcoming surgical experience is quite reasonable, but they nevertheless feel that surgery is a mind-
body experience and see preparation as a way to enhance this experience. Often such a patient
is quite sophisticated psychologically, has previous positive experience with self-regulation tech-
niques, and has a predisposition to active coping. Intervention with such patients usually consists
of supporting their use of self-regulation and assisting the focus on specific healing outcomes, such
as comfort, rapid healing, and rapid return to function using active coping strategies including
active self-participation.
By and large, the primary criterion for referral for surgical preparation has been some version of
psychological pathology, interfering with medical functioning or the normal functioning of the
institutional surgical process. This could be getting the normal set of injections or insertion of
the IV; demonstrating reasonable effect that does not translate into extra time in the surgeon’s
office or the anesthesia preoperative visit. Implicitly, it is as if there were a trait of psychological
distress about surgery. However, despite many efforts to observe such relationships, measures of
pathology have not consistently correlated with poorer surgical outcome (Salmon, 1993). Patients
may have greater anxiety before surgery or even have greater amounts of trait anxiety. However,
such presentations have not been demonstrated to consistently correspond to any specific negative
outcome dimension (Kessler & Whalen, 1999). In fact, it has been observed that there have been
functional or physiological improvements even when controlling for psychological pathology
(Salmon, 1994). Therefore, using observable pathology as the activator of surgical preparation,
while of value, is not the sole criterion to be considered. Other dimensions of functioning have
been demonstrated to compromise surgical outcomes, yet they are infrequently considered as
initiators of use of psychological surgical preparation.
As already mentioned, poor coping and compromised medical surgical history are related to
poorer outcomes of surgery and recovery. In addition, patients who have had multiple surgeries or
surgeries with compromised outcomes are likely to cope poorly with additional surgeries and there-
fore have greater need to be considered for active psychological preparation. Certain surgeries, such
as organ or body part loss, gastric bypass, or having a colostomy, require significant coping and
adaptation in preparation for the surgery and significant lifestyle changes afterward. Such proce-
dures have clear psychological dimensions that need to be, yet are infrequently formally, addressed.
Again, even in some of the studies that have only allowed patients without identifiable psycho-
logical co-morbidity to participate, clinical and cost benefits of preparation have been demon-
strated. This last point should be underscored. In an era where the cost of procedures and patient
care is under scrutiny, probably the largest group of patients who could benefit from preparatory
strategies do not receive them. This both increases patients’ personal distress and suffering, and
costs the health-care system large amounts of money based on the cost data that have been
generated in this field in the past 20 years.
Obstacles
It is assumed that most of the readership of this book have a more diverse knowledge base concerning
psychological interventions in medicine than the majority of the medical and psychological
community. It is further assumed that even for this readership this chapter has discussed somewhat
unfamiliar techniques and outcomes, compared with other aspects of medical psychology.
The observation is probably more focused if the readership includes surgeons and primary care
physicians. I have not read a family practice textbook, or a general surgery text, that provides more
than a cursory review of the psychological issues of patients undergoing surgery and no substantive
discussion of the psychological preparation of the surgery patient. This subject has been sufficiently
obscure that it has not appeared even as mainstream as other areas of behavioral medicine, despite
the length and substance of its research, its ease of use and transportability, and its savings to the
health-care system. Additionally, what is known is often limited and inaccurate, which has resulted
in the association between referral for surgical preparation and significant presentation of psycho-
pathology, or disbelief that such a brief psychological intervention could have such profound clinical
and cost consequences. Changing the current status is a complicated task. First, it involves substan-
tial education. Second, education is generally insufficient to change medical behavior. It is well
documented in the medical education literature that information is a necessary but not sufficient
intervention, and that giving physicians experience with the change, in their site, and assisting them
in learning and experiencing its value is an important component that influences physician behavior
change (Davis, Thompson, Oxman, & Haynes, 1992; Kroenke, Taylor-Vaisey, Dietrich, & Oxman,
2000). Third, such a shift cuts across multiple disciplines, and both outpatient and hospital practice.
The strategies that need to be employed must address the interests, needs, and concerns of each of
the disciplines, respecting and addressing the different organizations, medical staff departments,
hospital departments, and employing organizations. Each has a relationship and interest in patient
care, organization of care, and administrative issues that are involved in different aspects of the
clinical and administrative care that is part of surgery.
Another dimension that must be considered and resolved if psychologists are to be involved in
surgery preparation is the payment for psychological services. When a colleague and I first began a
surgical preparation service in our rural medical center, it received a front-page headline in the
largest newspaper in Vermont. This was followed shortly by a letter from the medical director of the
largest insurer in Vermont, wondering if we expected that they would pay for the service. After we
wrote them a letter outlining many of the points made in this chapter, and after they reviewed the
literature cited in this chapter, the matter was resolved to everyone’s satisfaction. However, despite
this, the financing of psychology in medicine is the same obstacle in this area of medicine as it is in
other areas of health psychology. In general, carve-out models of behavioral health do not assist
resolution because intervening with medical patients does not fit their model, which has relied on
limiting, not increasing, access to behavioral health care of any type. For them there is no incentive
to reasonably support medically and psychologically integrated care, since it would just increase
their expense target and reduce profit, and if a patient does not receive needed psychological prepa-
ration, the increased medical expense does not come out of their budget.
The Limitations of the Data and Need for Further Research

Despite the large and lengthy supporting literature that has been identified, there is still work to be
done. The models of organizing surgical preparation and the specificity of our interventions are not
quite as precise as a scalpel’s cut. Because this area of research has not been near the top of
the national research funding agenda, most of the treatment effectiveness studies have been
conducted at single sites with smaller samples than would be optimal. Large multiple-site trials
with consistent methodology and the same specified outcomes are needed. These trials need to
assess both intra- and postsurgical outcomes, but also longer-term follow-up of posthospitalization
function, such as return to work and ongoing medical utilization.
Given the auspicious data from studies reviewing the cost consequences of these interventions
and meta-analyses including cost, greater consideration needs to be given to evaluating the cost
consequences of both preparation before compared with during surgery and nonpreparation. Also,
there are different preparation models. In two of their published studies, Bennett and colleagues
(Bennett, Benson, & Kuiken, 1986; Disbrow, Bennett, & Owings, 1993) used a brief semistandardized
intervention that took less than 15 minutes while generating significant important outcomes, the
first demonstrating lowered blood loss during the surgery and the other rapid return of bowel
motility. This is contrasted with other models, such as my own work, which average around 1 hour
and include a standardized assessment and tailored intervention, as well as other variations of
intervention strategy.
Assessing Effectiveness
Once more there is the opportunity for research to inform practice. The variables that have been
used to demonstrate surgical preparation’s effectiveness in the research literature are available for
use in clinical practice. The variables used to assess the effectiveness of this medical intervention are
the variables that medicine notices. Analogue pain ratings are often regularly kept in patient’s
charts and are now more likely to be present due to attention on pain from the Joint Commission.
Also, data concerning premedication prior to surgery is available, as are amounts of postoperative
pain medications. Nursing notes, usually containing observational data about patients’ overall and
psychological function and length of hospital stay, are easily available. However, the best measure in
terms of changing physician perception and behavior is seeing the changes in individual functioning
of their patients. As powerful as the measurable outcomes have been to my success, one surgeon’s
report to his colleagues of a remarkably labile and difficult patient was probably just as important.
The surgeon had labeled the patient the most emotionally difficult patient he had ever worked with
during her first surgery, but after a preparation the patient had an easy, rapid surgery and recovery
and early discharge.
Summary
This chapter started with the proposition that there has been successful development of clinical
technologies to demonstrate that over a lengthy period of time, psychological preparation for
surgery and invasive medical procedures is an effective intervention that has demonstrated clinical,
administrative, and financial benefits to patients and the medical system. It is not quite as precise as
a scalpel’s cut, however, because greater specificity and commonalties of outcomes to be measured
need to be defined. More work needs to be done concerning the contribution and implications of
individual differences, and greater clarity in matching procedures to patient subtypes needs to be
demonstrated. But even with these constraints it should be clear that this is a technology that
should be endorsed to patients, physicians (especially in primary care), nurses, administrators, and
insurers. It is disappointing to say that presently such endorsement has fallen on mostly deaf ears;
therein lies the task.
In some areas of health psychology there is openness to the provision of adequately developed
technical solutions. I would say that smoking cessation fits that bill, where despite great efforts and
some promise, there is a clear limitation in the effectiveness of the technology. Preparation for
surgery suffers from the converse. There is a demonstrated effective technology waiting for the
opportunity to be used. The primary tasks in this clinical area are no longer developing a treatment
technology. Rather the task is reengineering primary care medicine to regularly include screening
for patients who are at risk for compromised psychological and physiological surgical outcomes
because of psychological distress. If this can be accomplished we need to move on to integrated
systems of referral and cotreatment to lessen or eliminate these risks and to provide improved
patient care. Surgery does not begin with the scalpel’s cut. It begins with a system of care that
respects both the mind’s and the body’s contribution to functioning, to healing, to living. That is
our contribution, and our patients deserve nothing less.
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Chapter 15
Assessment and Treatment of Chronic Benign
Headache in the Primary Care Setting
JOHN G. ARENA AND EDWARD B. BLANCHARD
Chronic pain (that is, pain that lasts for at least 6 months), with the exception of influenza and the
common cold, is the most frequent cause of visits to primary health-care settings (Sobel, 1993), and
presents an extremely frustrating challenge for most traditional medically oriented health-care pro-
viders. Headache is one of the most common pain complaints, and research has shown that over a
10-year period from 1987 to 1996, primary care providers have seen an increasing number of indi-
viduals with pain-related diagnoses primarily due to an increase in headache patients (Andersson,
Ejlertsson, Leden, & Schersten, 1999). Khan, Khan, Harezlak, Tu, and Kroenke (2003) have noted
that headache is a particularly refractory diagnosis for primary care providers. The direct health-
care costs of headaches are significant (Mannix, 2001), and the cost of headaches to employers is
exceedingly high. In a study that examined lost workdays and decreased work effectiveness associated
with headache in the workplace, Schwartz, Stewart, and Lipton (1997) found that headache sufferers
lost the equivalent (they accounted for both actual lost workdays and reduced effectiveness at work)
of 4.2 workdays per year because of headache.
A large body of literature on both the pharmacotherapy and psychological treatment of headache
has emerged during the past three decades. Reviews of the behavioral literature have generally
shown two techniques, biofeedback and relaxation therapy, to be effective in significantly reducing
headache activity in 40–60% of both tension and vascular (migraine and combined migraine-tension)
headache patients (Arena & Blanchard, 2000; Blanchard & Arena, 1999; Costa & Vandenbos,
1990; Craig & Weiss, 1990; Gatchel & Blanchard, 1993; Holroyd, 1993; Shumaker, Schron, &
Ockene, 1990). In this chapter, we will review the basics of nonpharmacological treatments for
migraine and tension-type headaches (the two major types of headache categories), placing special
emphasis on the frontline mental health professional in a primary care setting. Whenever possible,
we will include clinical guidelines that are based on both the available research literature and our
clinical experience.
293
Characteristics of Migraine and Tension-Type Headache

Clinicians who work with headache patients should use a standardized set of inclusion and exclusion
criteria for diagnosis, such as those of the Ad Hoc Committee on the Classification of Headache
(1962) or the newer Headache Classification Committee of the International Headache Society (1988).
Migraine headache is episodic and characterized by a throbbing/pulsating/pounding type of
pain that generally starts on one side of the head, although as the headache progresses, it often
encompasses both sides. It typically starts over an eye or in the temple region and can last anywhere
from 2 hours to 3 days. Frequently it is accompanied by nausea and, sometimes, vomiting, as well as
sensitivity to noise (termed phonophobia) and, especially, light (termed photophobia). A migraine
can occur on a frequency of two a week to only one or two a year; the average migraineur has one to
two headaches a month. Approximately 10% of migraine headache patients have a prodrome—that
is, preheadache symptoms that can occur up to 30 minutes before a headache, such as seeing flashing
lights or squiggly lines, experiencing a disturbance in speech, or a tingling feeling in the arms or
hands. Those migraine headache sufferers with a prodrome are described as classic migraineurs;
those without a prodrome are termed common migraineurs.
Tension headache is generally less episodic and is characterized by a steady, dull ache or pressure
that is generally on both sides of the head. It is sometimes described as a tight band or cap around
the head, a soreness, a nagging, or a vice-like pain. It typically begins in the forehead, temple, back
of the head and neck, or shoulder regions, and encompasses the entire head. A tension headache
can last from 30 minutes to 7 days. If headache occurs less than 15 days a month, it is termed
episodic tension-type headache; if the headache is experienced 15 or more days a month, it is
termed chronic tension-type headache. The pain associated with tension headache is considered to
be of generally lesser intensity than that of migraine headache.
Up to half of patients with migraine headache also meet the criteria for tension headache. These
individuals have been labeled as having “Mixed Migraine and Tension-Type Headache” or “Com-
bined Migraine and Tension-Type Headache.” Most clinicians and researchers have typically
lumped both pure migraine and mixed migraine and tension headaches together under the label of
“Vascular Headache” and treated them similarly.
Headaches are a true biopsychosocial phenomenon, affecting psychological and social factors of
an individual’s life as well as the more obvious physiological concerns. Depression, anxiety, and
anger are common sequelae of headache, as are dysfunctions in occupational areas, such as lowered
job productivity and increased days off from work, and interpersonal relations, such as being
unable to participate in family outings and social functions (e.g., parties, picnics, etc.). Of course,
the reverse is also true, that psychological and social factors affect headache intensity, frequency,
and duration. For example, psychological stress has been shown to exacerbate and bring on head pain.
Epidemiology of Migraine and Tension-Type Headache

Tension-type headache is believed to be the most prevalent form of headache. It is more common
in females than males, with a male-to-female ratio of approximately 1:1.5 (Rasmussen, 1999). Age
of onset is generally in the second decade, and it peaks between the ages of 30 and 39. Rasmussen,
Jensen, Schroll, and Olesen (1991), using the diagnostic criteria of the International Headache Society,
found that lifetime prevalence of episodic or chronic, tension-type headache was 78% for men and
women combined, 69% for men, and 88% for women. In that study, the prevalence of tension
headache in the previous month was 48% overall. Interestingly, among subjects with migraine in
the previous month, 62% had coexisting tension headache. This study is extremely important
because it is the first investigation to include a representative random population, to use opera-
tional diagnostic criteria, and to include a clinical interview as well as a general physical and
Assessment and Treatment of Chronic Benign Headache • 295
neurological examination of all participants. It suggests that the incidence and prevalence of
chronic tension headache is much higher than previously believed. Silberstein and Lipton (2000)
estimated that 4–5% of the U.S. population suffer from primary chronic daily headache, of which
the majority are tension-like.
Migraine headache is predominantly a disorder of women during the childbearing years. In pre-
pubertal children, migraine is approximately equally distributed across the sexes. With the onset of
menarche, females having migraines begin to outnumber males by about 2 or 3 to 1. An outstanding
epidemiological survey (Stewart, Lipton, Celentano, & Reed, 1992) involving over 20,000 partici-
pants across the United States found 17.6% of females and 5.7% of males have one or more
migraine headaches per year, with almost 4.5 million adults suffering from one or more migraine
headaches per month. (In our experience, women outnumber men by 4 or 5 to 1 in terms of seeking
psychosocial treatment for migraine headaches.)
Establishing a Relationship With a Primary Care Provider: The Clinician’s Initial Task
While not always essential for high-quality treatment per se of the headache patient, if at all possi-
ble, the psychologist should try to establish a relationship with primary care providers who have
sent, or will likely provide, referrals. Optimally, one should establish this relationship prior to
receiving any referrals from the primary care provider. This is easily done if the behavioral health-
care provider operates in the same setting as the primary care provider and is located in the
primary care clinic or office. Daily interactions with providers are therefore easy and expected.
Often, the mental health professional has lunch or coffee with the primary care providers, meets
them in the hall and informally discusses cases, and so forth. Unfortunately, it is often the case that
the mental health professional is not integrated into the primary care setting, and this makes it
quite difficult to establish such relationships. Sometimes establishing such relationships before
receiving referrals is not feasible, especially in medical schools or a teaching hospital where large
numbers of students, residents, and staff rotate frequently through the primary care setting. Estab-
lishing an alliance with the primary care provider will likely pay dividends, not only with headache
sufferers currently being treated, but with subsequent headache patients. Taken as an aggregate, we
have found that primary care providers are more receptive to psychological approaches to chronic
pain than are other medical specialists, such as those in orthopedics, neurology, or neurosurgery,
although there is great variability among providers.
As noted above, being integrated into the primary care clinic or offices is preferable, and it
makes it easy to establish a relationship with the primary care providers. However, this often is not
the case. If you are located in a hospital or clinic and are operating in the same setting as the
primary care providers, we suggest the preferred method is to walk to the primary care provider’s
office and introduce yourself. It is important to keep in mind that primary care providers are usu-
ally extremely busy, so limit your initial visit to a brief greeting. Then set up a longer stretch of time
(no more than 20 minutes, however) to explain in outline form what services you can offer. Keep it
very pragmatic and avoid the use of jargon. If you are a psychologist in private practice and your
office is located some distance away from the primary care provider’s office, getting acquainted by
phone will do the trick.
In your interactions with primary care providers, in addition to letting them know what you can
do and what you are about, we would urge you to briefly discuss your strengths and weaknesses.
(This, of course, necessitates that you are aware of your strengths and weaknesses. If you are not,
simply ask your spouse, children, or friends!) If you do not work well with certain popula-
tions—such as the mentally retarded or individuals who are extremely angry or ruminative—let
them know that and if possible furnish them with the names of individuals who do work well with
such populations. Above all, do not promise more than you can deliver. That is by far the biggest
mistake psychologists and other mental health professionals who work in primary care settings or
with primary care providers make. We have found that when you are dealing with health-care pro-
fessionals, a little humility goes a long way. Discuss in a realistic way the clinical outcome data
(detailed below) on the nonpharmacological treatment of headache and always remember that the
stringent inclusion and exclusion criteria employed in most research protocols (i.e., they generally
exclude individuals with major depression or who have serious medical illnesses, etc.) probably influ-
ence that data in a positive direction. This initial interaction will pave the way for subsequent meet-
ings and “prime the pump” for the beginning of a two-way learning process between the primary
care provider and the mental health professional.
Two final notes here: First, the adage about not promising more than you can deliver applies to
both primary care patients and providers. Second, for those mental health professionals located in
primary care clinics, we have found that the optimal place for an office is in the quietest part of the
clinic, as far away as possible from the examination and procedure rooms. The examination and
procedure rooms are generally very active, noisy places that are usually not conducive to nonphar-
macological interventions. In this way, the primary care provider or his or her staff can walk the
headache patient over to your office, and you can briefly introduce yourself and schedule an
appointment. This significantly reduces initial no-show rates.
Understanding the Primary Care Provider’s Practice Style and Preferences and Beginning a
Collaborative Process: The Clinician’s Next Task
The collaborative process that a mental health professional has with the primary care provider can,
depending on circumstances, be either extremely rewarding or punitive. A great deal depends on the
mental health clinician’s obtaining an understanding of the practice style and personal preferences
of the primary care provider. The process that underlies this is a subtle one that begins with the ini-
tial introduction and continues along the life of the relationship. There are some things, however,
that we feel are nearly always useful for the mental health provider to discover about the primary
care provider.
One of the most important things to ascertain about primary care providers is how they prefer
obtaining information about the status of their patients. Some providers want you to keep them
updated constantly, with a copy of the initial report faxed to them, coupled with an e-mail, phone
call, or fax after each treatment session, as well as a copy of the termination report. Others simply
want a copy of the initial report and termination report, yet others feel that once they send you the
patient he or she is “owned” by you (a terrible phrase that is unfortunately used by too many
health-care providers) unless they hear otherwise. Deciding what is the referral source’s preferred
style of communication regarding status of patients is essential for the psychologist or other mental
health professional working in a primary care setting. It is easy to irritate providers by sending them
too much or too little information. In our experience, the vast majority of primary care providers
wish to be updated periodically about patients’ status, usually at the beginning of treatment with
your clinical impressions and at the end of treatment with a global percentage of improvement and,
if the patient did not achieve sufficient relief, suggestions for further treatment or referrals. But do
not assume this—ask. Furthermore, do not always assume that primary care providers accurately
provided their true desires concerning how often they wish to be updated regarding a patient’s
status—sometimes they give the response they believe they should give or the response they assume
you would want to hear. As you treat a few of their patients and get to know your referral sources,
you will discover whether the information they gave you initially was accurate, and you can modify
your information delivery style as necessary. For example, a provider may have initially told you
that he or she wanted information on a patient only after treatment is completed. However, if that
provider repeatedly calls you about the patient’s progress, you can infer that he or she really wants
periodic updates. You should then change your frequency of reporting on that provider’s patients.
We also find it helpful to tell the primary care provider that if certain things change regarding
the headache (for example, the headache characterization changes, switches location, or suddenly
becomes constant and unremitting, or the patient suddenly loses coordination, or gets drowsy or
confused when she has a headache), you will immediately let him or her know about these changes.
This lets the primary care provider know that you are aware of the medical aspects of headache, and
that you respect his or her discipline.
Another rather delicate issue to touch upon is the personality, reasoning, and desires (conscious
or unconscious) underlying the referral from a provider. An overall feeling about this generally
comes after receiving a couple of referrals from the provider. If at all possible, try to find out what
the provider really wants from the referral and why the provider is truly referring the patient to you.
The documented referral question does not always contain the only reason for a referral. It is
important to keep in mind that a primary care provider will not generally refer a headache sufferer
to a mental health professional unless the patient has proved refractory to a number of pharmaco-
logical and medical interventions.
Does the primary care provider want the mental health provider to give him/her absolution, to
say that it was not his/her fault that this patient did not improve, that no primary care provider
could help this patient? If this is the case, it is important to include phrases such as, “this very diffi-
cult pain management case” or “this complex pain problem” in your report. As you develop a
relationship with that particular provider, you may wish to do some brief psychotherapeutic inter-
ventions concerning this attitude. For example, in your conversations with the primary care
provider, you can delicately discuss how difficult you find some of these patients to work with, how
having patients that prove refractory to treatment can be frustrating, and here is how you and
others have dealt with such types of patients, etc.
Does the provider want you to identify whether the patient has significant psychological prob-
lems that interfere with medical treatment response, but really does not want you to treat the
patient? Some primary care providers do not want a mental health professional to be involved in
the headache treatment process, but they want to understand better the psychological makeup of
their headache patients. In this instance, education and time are your best assets, because as the
provider gets more information concerning the psychological aspects of headache, the provider will
quickly see the benefits of nonpharmacological treatment (as well as the fact that it takes specialized
skills to help their patients).
Is the primary care provider referring the headache patient because this a very difficult patient
that the provider wants to dump on the mental health professional? If this is the case, and the men-
tal health professional will quickly realize this—generally after four or five completely inappropriate
consults who have failed to respond to nonpharmacological treatment (if they make the mistake of
treating them)—psychoeducation will typically in our experience fail. Generally the best approach
is to discourage that particular provider from sending referrals.
Is the provider at his or her wits’ end and going on a “fishing expedition” in the hopes of
finding something that might work? This is the most common nonstraightforward referral pattern,
and it is actually easy to deal with. Education about when to send a patient to a mental health
professional—hopefully well before a primary care provider gets to the “end of his/her rope”—
usually also does the trick here.
Finally, does the provider want some excuse not to treat this patient, and is hoping that a
psychologist’s report will give him or her the justification? Here, education of the provider about
when to transfer a patient to another primary care provider, and discussion of transference and
countertransference (if appropriate to the primary care provider’s level of sophistication about
psychological factors) is appropriate. One way to do this is to discuss difficult patients you have had
and how you have had to transfer patients to other mental health providers because you just could
not work with someone. Usually, this will begin a dialogue that most medically oriented professionals
have never had and they are often grateful for the chance to discuss such a sensitive topic.
One way some mental health professionals try to help both themselves and the referring
provider is to have either a separate checklist that providers can then attach to consults, or a list of
usual reasons for referrals to the mental health professional that they can refer to when formulating
referrals for difficult patients. The referral slip (e.g., sort of a “check the box” slip), that does not go
in the actual chart, delineates reasons for referral (e.g., patient is refractory to numerous treat-
ments, I believe there may be mental health problems; I think that this patient is depressed; etc.)
that the medical care provider would fill out and give to the mental health care provider. This is
often a useful tool for the mental health professional in the primary care setting.
Another personal preference that is useful for the mental health provider to ascertain concerning
a respective primary care provider is his or her interest in the headache and psychological clinical
research literature. Some primary care providers enjoy reading research articles, and others do not.
Some prefer review articles, chapters, or books to research articles. Some enjoy reading about
pharmacological or medical approaches to headache, but wish no information about nonpharma-
cological approaches. (Here one needs to be careful, as the mental health provider does not wish to
be seen as stepping into the primary care provider’s turf. If we do provide such information, we
usually provide an article that compares a nonpharmacological approach with a pharmacological
one.) Some primary care providers enjoy getting articles about headache epidemiology, others
about pathophysiology. Still others do not want any educational materials—at least not those given
to them by a mental health professional. Determining the provider’s style concerning educational
aspects of the relationship comes with experience and time, generally after the mental health
professional has established a personal relationship with the primary care provider.
The Clinical Interview, Headache Diagnosis, and Nonpharmacological Treatment Prognosis:

The Initial Step With Every Headache Patient
The first formal step in any assessment procedure involves conducting an extensive headache
history, which is necessary in determining a diagnosis. The clinical interview for a headache patient
is the clinician’s most valuable tool, not only for diagnosis but also for prognosis. The interview we
currently use is a slightly modified version of one used in previous research and requires about 60
minutes to complete. We have published (Blanchard & Andrasik, 1985) this version of our clinical
interview. For readers wishing a revised version, please contact the authors.
The clinical interview for a headache patient is very similar to the clinical interview for a psychi-
atric patient, with one major exception: it is important that the mental health provider avoids talking
about psychological issues for at least the first half of the interview. This way one avoids having the
patient attempt to characterize the mental health professional as a “shrink” who is not really inter-
ested in his or her pain. If patients tell you that they feel like harming themselves when their pain is
severe, or that they use alcohol to attenuate their pain, or that stress makes their pain worse, do not
deviate from your initial goal of obtaining information about their headache, do not start asking
questions concerning suicide, alcohol abuse, or stress. If the patient persists in wanting to talk about
psychological problems before the headache aspects of the interview are completed, we say: “I really
want to find out all about your pain now. I promise you we’ll discuss these other issues later.”
The headache interview should, of course, cover the history of the patient’s headaches. Intensity,
duration, and frequency should be reviewed, as well as where the headache starts, how it progresses
over time, associated symptoms, what exacerbates the head pain, is there a menstrual relationship,
what attenuates the head pain, family history of headache, and so forth. One of the most important
questions to ask is whether patients have more than one kind of headache. If they answer yes to this
question, we would urge you to take a separate headache history for each type of headache, to ascer-
tain whether they do, indeed, suffer from combined migraine-tension headache. Sometimes
patients state they have more than one kind of headache but, upon examination, they are making a
differentiation based on intensity or location alone. This does not meet the criteria for combined
migraine-tension headache.
Another important question to ask is, “How would you describe the pain? Is it a dull ache,
throbbing, burning, piercing, cramping, sharp, or an electric pain?” Here you are looking not only
at the descriptors, but the manner in which they describe the pain. Generally, the clinician is looking
for extremes. Individuals who matter-of-factly state, “It’s a bad pain” or who floridly state, “It’s like
a spider web of pain, a labyrinth of agony. It feels like my brain is too big for my skull—like some-
one is taking a skinny pair of pliers and twisting and pulling my brain out through my eyeball,” are
both, in our clinical experience, poor treatment responders.
Another thing to explore in the clinical interview is possible secondary gains, that is, overt
reasons why it may be beneficial for a person to create or maintain his or her headaches. The usual
sources are: spouse (attention, acceptable reason for decreased sexual activity, decreased nagging,
etc.), children and grandchildren (attention, quiet, reason for them to stay at home and not date,
etc.), work (socially acceptable reason to not work), financial remuneration (paid sick leave, litiga-
tion, disability), and that pain is often a socially acceptable reason to not participate in activities
such as church, parties, picnics, dancing, sports, and so forth. Clinically, we have found that the
presence of significant secondary gains is a good predictor of poor treatment outcome.
In addition to obtaining a complete headache history, it is important to ask about what is going
on in the headache patient’s life. Issues such as marriage, work, how they get along with parents,
etc., are vitally important. If they ask why you are inquiring, we tell them: “We know that most pain
is made worse by stress, so we’re looking for possible areas of stress in your life.” Another significant
area of inquiry is to ascertain what they do on a typical day. This will give you important informa-
tion about their activity level, as well as insight as to why they may be depressed. For example, many
individuals with chronic daily tension or combined migraine-tension headache have days that con-
sist mainly of staying at home and watching television. This, of course, leads to elevated levels of
depression, as well as poor muscle tone. High levels of depression and anxiety have both been
found to be good predictors of poor treatment outcome for nonpharmacological interventions.
Above all, do not skip the mental status examination. Many clinicians feel that since they are dealing
with a headache patient, they do not need to do a formal mental status examination. However, we
feel that such questions are vitally important. For example, we know that headache patients who are
significantly depressed have much worse outcomes than those who are not, and some headache
patients are schizophrenics with somatic delusions. Every clinician has stories of individuals who
seem to be functioning within normal limits until the very end of the interview when, responding
to a question such as, “Do you have any special powers?,” report that, “I cause the sun to rise every
morning and set every evening.” If you overlook the mental status examination, you overlook
vitally important clinical information.
It is important to reflect on the interview process upon completion of the interview. Questions
the mental health provider should ask him/herself are: Were there antisocial personality traits
present? Were there histrionic personality traits present? Was there hostility or inappropriate anger
present? Was the patient trying to present him/herself in an unusually good light (e.g., “everything
would be perfect in my life if it were not for this darn pain”)? In our clinical practice, we have found
that these characteristics retard the treatment process.
Other prognostic indicators of poor treatment outcome are: pain that is constant, pain that
remains at the same level throughout the day regardless of activity level (i.e., it is always an 8 on a
scale of 1 to 10), a diffuse pain (“It’s all over”) as opposed to a specific pain (“It’s right over my
eye”), pain that is in multiple areas of the body, individuals who are involved in litigation or have
quit their jobs as a result of the headaches, headache sufferers who have no or a large number of
associated symptoms, patients who have previously proved refractory to nonpharmacological
intervention, and individuals with preexisting psychiatric conditions. Unfortunately, in the non-
pharmacological treatment of headache, the prognostic indicator of good treatment outcome is
generally the absence or low number of prognostic indicators of poor treatment outcome. Tables
15.1 and 15.2 present brief checklists of prognostic indicators of poor and good treatment outcome.
All information obtained in the clinical interview should be included in the body of the consul-
tation report. Very often patients will tell the mental health professional things that they have not
told their primary care provider. Often, patients believe that they have told their primary care
provider information that they have not. Therefore, as a rule, we include all information in the
consultation report. Major points are covered in a section that we term, “Summary and Recom-
mendations.” Less important points are placed in a section that we term, “History and Interview Data.”
There is certain information that the mental health professional may obtain during the clinical
interview that requires immediate consultation with the primary care provider, rather than simply
noting it in the consultation report. Many of these are obvious, such as a patient who admits he or
she is a substance abuser or is suicidal. Other less-apparent instances are when patients decide to
discontinue medication on their own, use more than the prescribed dosage, or enhance the effects
with alcohol. It is also prudent to alert the primary care provider when patients complain of new
sensory or motor deficits that occur before or during the headache that are not typically associated
with migraine prodromes, such as weakness or numbness in an extremity, or twitching of the hands
or feet, as the patient may have had a stroke. Aphasia or slurred speech may be caused by a vascular
malformation. Twitching—especially on one side of the face or in only one hand—could indicate
focal seizures due to a tumor or other structural lesions. If the patient has had some trauma to the
head since being seen by the primary care provider, especially if unconsciousness occurred even
momentarily, immediately alert the primary care provider. This matter is even more urgent if the
topography of the headache has changed since the trauma. If the patient’s headaches have gone
from being intermittent and variable in intensity to constant and unremitting, alert the primary
care provider. If the patient has tension headaches and the intensity has been steadily increasing
over a period of weeks to months with no relief, alert the primary care provider because the head-
ache may be due to uncontrolled hypertension or a tumor causing increased intracranial pressure.
If the patient’s family tells you that there has been a noticeable change in behavior, personality,
memory, or intellectual functioning recently, alert the primary care provider as this may be indica-
tive of a frontal lobe tumor. If the patient complains of sudden onset of headache during exertion
(lifting/weight training, sexual intercourse, heated arguments, etc.) alert the primary care provider
as this may be due to a leaking cerebral aneurysm. Finally, if the patient tells you of any family his-
tory of vascular abnormalities, polycystic kidneys, or cerebral aneurysm, immediately notify the
referring primary care provider, as the patient may not have informed the provider about this fam-
ily history.
The Headache Diary: The Clinician’s Next Step With Every Headache Patient
At the first visit, you should have the patient begin to record a daily headache diary. In this diary,
the patient notes degree of headache activity using a 6 (0–5) point scale, an 11 (0–10) point scale, or
a visual-analogue scale, generally four times a day (awakening, lunch, dinner, bedtime). We have
TABLE 15.1 Prognostic Indicators of Poor Response to Nonpharmacological Treatment

_____ Antisocial personality traits present to a significant degree (i.e., married numerous times, long history
of substance abuse, long arrest record, history of fighting, etc.)
_____ Atypical headache
_____ Cognitive functioning at low levels
_____ Constantly present headache
_____ Depression that is at a moderate/severe/marked level
_____ Diffuse pain (i.e., “It’s all over my body”)
_____ Extremely dramatic pain presentation
_____ Extremely matter-of-fact pain presentation with no affect (only when discussing pain)
_____ Few associated symptoms (e.g., dizziness, difficulty walking, crying, concentration problems, anger,
stomach problems)
_____ More than seven associated symptoms (e.g., fatigue, loss of bladder control, blurred vision, irritability,
depression, profuse sweating)
_____ Headache that is always at the same intensity level (i.e., pain level unchanged regardless of activities)
_____ Histrionic personality traits present to a significant degree (i.e., dramatic presentation throughout the
interview, flirtatiousness, etc.)
_____ Hostility or inappropriate anger present to a significant degree
_____ Litigation pending or ongoing
_____ Low motivation level
_____ Significant MMPI-2 findings: (a) invalid profile (especially if they attempted to “fake bad”); (b) scale 1
> 70T; (c) scale 3 > 70T; (d) scale 4 > 65T (check Harris and Lingoes subscales to make sure not due
to family problems) (e) scale 6 > 70T; (f) scale 8 > 75T (not due to bizarre sensory
experiences—check Harris and Lingoes subscales); (g) presence of conversion V—scales 1 and 3 >
65T and scale 2 at least 10 T points lower than 1 and 3.
_____ Multiple types of pain or multiple pain sites
_____ Patient trying to present in an unusually good light (e.g., “Everything would be perfect in my life if it
were not for this darn pain”)
_____ Patient very skeptical about the effectiveness of nonpharmacological treatments (“That stuff just
doesn’t work”)
_____ Poor work history (particularly prior to onset of headaches)
_____ Preexisting psychiatric conditions
_____ Previously failed nonpharmacological interventions
_____ Secondary gains:
_____ Children and grandchildren (attention, quiet, reason for them to stay at home and not date, etc.)
_____ Financial remuneration (paid sick leave, litigation, disability)
_____ Socially acceptable reason to not participate in activities (such as church, parties, picnics, dancing,
sports, etc.)
_____ Spouse (attention, acceptable reason for decreased sexual activity, decreased nagging, etc.)
_____ Work (socially acceptable reason to not work)
_____ Typical day consists of few activities and pleasant events
_____ Quit job as a result of headaches
TABLE 15.2 Prognostic Indicators of Good Response to Nonpharmacological Treatment

_____ Antisocial personality traits not present to a significant degree (i.e., married only once or twice, no
history of substance abuse, no arrest record, no history of fighting, etc.)
_____ Appropriate number (between 3 and 6) of associated symptoms (e.g., dizziness, difficulty walking,
crying, concentration problems, anger, stomach problems)
_____ Cognitive functioning at normal or above levels
_____ Good work history (particularly prior to onset of headaches)
_____ Headache follows typical pattern
_____ Headache intensity changes
_____ Headache is intermittent, not constant
_____ Histrionic personality traits (i.e., dramatic presentation throughout the interview, flirtatiousness, etc.)
not present to a significant degree
_____ Hostility or inappropriate anger not present to a significant degree
_____ Litigation not pending or ongoing
_____ Moderate or greater motivation level
_____ No depression present or present at low levels
_____ No easily observable secondary gains
_____ No history of poor response to nonpharmacological interventions
_____ No preexisting psychiatric conditions
_____ No significant MMPI-2 findings
_____ Normal pain presentation (i.e., not dramatic or matter-of-fact)
_____ Pain localized to headache only
_____ Patient not trying to present in an unusually good light
_____ Patient expresses strong belief in the efficacy of nonpharmacological interventions
_____ Patient referred by someone who was a nonpharmacological treatment success (or patient knows
someone who was a success)
_____ Typical day consists of many activities and pleasant events
generally used the 6-point scale, but there is no evidence suggesting any one scale is more advanta-
geous than another. Medication usage can also be recorded.
Measures generally derived from the headache diary are (1) The average daily headache activity
score per week, termed the headache index. This is the most sensitive and frequently used measure
since it combines intensity and duration. (2) Number of headache-free days per week. (3) The
highest, or peak, single headache rating for each week. This measures whether the more debilitating
headaches are being relieved. At the end of one week, we usually have the patient return to have the
diary checked. If the records are not being adequately kept, the procedures should be explained
again. Although ideally the headache diary should be kept for at least 28 days before treatment
starts for vascular headache sufferers, and for 7 to 14 days for tension headache patients, one needs
at least 2 weeks of diary for vascular headache and 1 week for tension headache.
The headache diary is essential for documenting treatment results. It can also give the provider
an indication of how well patients will adhere to the treatment regimen. Obviously, if the patient
cannot correctly fill out the diary or refuses to fill out the diary, that is likely a harbinger of poor
treatment results. It is certainly “grist for the therapy mill”—that is, inquiry about why the patient
is having problems with the diary will likely lead to discussion of areas of possible stress in his or
her life or salient personality characteristics that would need to be addressed by the mental health
professional. If a patient adamantly refuses to fill out a headache diary, however, we generally will
continue to treat him or her, although many clinicians would not. Appendix A includes a sample of
a headache diary.
Psychological Testing
Readers interested in an in-depth discussion of the personality factors associated with headache and
the nuts and bolts of psychological testing with headache and pain patients should avail themselves
of the excellent reviews that are already available (e.g., Block, 1996; Cao, Zhang, Wang, Wan, &
Wang, 2002; Holroyd, Stensland, Lipchik, Hill, O’Donnell, & Cordingley, 2000; London, Shulman,
& Diamond, 2001; Turk and Melzack, 1992). We believe that psychological testing is not always
necessary or cost-effective with headache patients, especially given the generally high rates of
success of nonpharmacological treatments (see below). Clinically, unless we can identify certain
markers during the headache interview, we do not administer psychological tests with headache
patients. Indications that psychological testing may be helpful include significant depression, anxi-
ety, or anger; and a history of physical, sexual, or substance abuse.
There are many instruments that the mental health professional can use to assess their pain
patients personality characteristics (e.g., Beck Depression Inventory, MMPI, Million Clinical Multi-
axial Inventory, Million Behavioral Health Inventory, SCL-90, Spielberger State-Trait Anxiety
Inventory, Spielberger Anger Expression Inventory, etc.), and cognitive factors such as pain beliefs
and coping styles (e.g., Coping Strategies Questionnaire, McGill Pain Questionnaire, Vanderbilt
Pain Management Inventory, Ways of Coping Checklist, etc.). From the primary care perspective,
we would advance that, for personality assessment, the MMPI-2 should be strongly considered for
use with headache patients. Our reasoning is threefold. First, the MMPI-2 is the most widely
employed psychological test, generating more research literature than any other instrument (Green,
2000). Second, most primary care providers know of and respect this test. Frequently those mental
health professionals working in a teaching hospital will get consults requesting “MMPI” when new
residents and fellows come onboard. (They are quickly educated about appropriate psychological
testing consults, of course.) Third, and most important, from our clinical experience, it has seemed
to answer our needs better than most other instruments. As the reader will see below, high levels of
anxiety and depression are predictors of poor treatment response.
Descriptions of the Three Major Psychological Treatment Modalities
Biofeedback Training
Biofeedback, as it is generally employed at the present time, is a procedure in which a therapist
monitors a patient’s bodily responses (such as muscle tension, surface skin temperature, or
heart rate) through the use of a machine and then relays this information back to the patient.
The physiological feedback is usually supplied to the patient either through an auditory modality
(e.g., a tone that goes higher or lower as muscle tension goes higher or lower) or a visual modality
(e.g., a computer screen where surface skin temperature is graphed on a second-by-second basis
during each minute or, more simply, the actual skin temperature in degrees Fahrenheit is pre-
sented). Through this physiological feedback, it is assumed that over time a patient will learn how
to control his or her bodily responses. A more formal definition of biofeedback is
a process in which a person learns to reliably influence psychophysiological responses of two

kinds: either responses which are not ordinarily under voluntary control or ordinarily are
easily regulated but for which regulation has broken down due to trauma or disease (Blanchard
& Epstein, 1978, p. 2).
There are two major modalities of biofeedback for chronic headache: EMG or electromyo-
graphic activity biofeedback, and thermal or surface skin temperature biofeedback. In EMG
biofeedback, sensors are placed on the forehead, neck, or shoulders and tension headache patients
are taught to decrease their muscle tension, as it has traditionally been assumed that tension head-
aches are caused by elevated levels of muscle tension in these muscle regions. It is also believed that
learning to decrease EMG levels enhances an individual’s ability to deal with stressful situations.
In temperature biofeedback, a small temperature-sensitive device is attached to the skin, usually
the fingertips, and vascular headache patients (migraineurs and mixed migraine-tension headache
sufferers) are taught to increase their hand temperature. It is believed that increasing one’s hand
temperature decreases overall stress levels, decreases sympathetic nervous system arousal, and
increases peripheral vasodilation.
Relaxation Therapy
Relaxation therapy is a systematic approach to teaching people to gain awareness of their physiological
responses and achieve both a cognitive and physiological sense of tranquility without the use of the
machinery employed in biofeedback. There are various forms of relaxation techniques (see
Lichstein, 1988, or Smith, 1990, for excellent reviews of the various types of relaxation therapy).
The major relaxation therapies employed today, however, are progressive muscle relaxation therapy
(Bernstein & Borkovec, 1973; Jacobson, 1929), meditation (Lichstein, 1988), autogenic training
(Luthe, 1969-1973), and guided imagery (Bellack, 1973). By far, the most widely used relaxation
procedures in headache are variants of Jacobsonian progressive muscle relaxation therapy and
guided imagery, and when we discuss treatment outcome we will be mostly emphasizing those
procedures. We have elsewhere described in detail a nine-session abbreviated Jacobsonian progres-
sive muscle relaxation therapy regimen that we have used with our headache patients (Arena &
Blanchard, 1996).
Because relaxation therapy and biofeedback are believed to directly influence both an individ-
ual’s physiology and psyche, they are commonly referred to as psychophysiological interventions,
and we shall refer to them this way throughout the remainder of this chapter.
Cognitive Behavioral Therapy

Cognitive behavioral therapies for headache are based on the assumption that an individual’s
thoughts, emotions, and behaviors influence his or her physiology. Therefore, cognitive behavioral
treatments generally involve identifying thoughts, emotions, and behaviors that routinely precede
or exacerbate headache activity, with the therapist subsequently teaching patients in a systematic
manner to modify these thoughts, feelings, and behaviors. Cognitive behavioral therapies are
generally combined with relaxation or biofeedback procedures. We have elsewhere described in
detail our cognitive behavioral procedures (Arena, 2002; Blanchard & Andrasik, 1985).
Treatment of Headache in the Primary Care Setting

The actual treatment of headache in the primary care setting is much the same as treatment of
headache outside the primary care setting. For a much more detailed how-to description of the
EMG and thermal biofeedback procedures, interested readers are referred to Arena and Devineni
(in press); Arena and Blanchard (1996, 2000, 2002); for details on relaxation therapy, please refer
to Arena, Bruno, Hannah, and Meador (1995), or Arena and Blanchard (1996); for additional
information concerning cognitive behavior therapy, please refer to Blanchard and Arena (1999) or
Blanchard and Andrasik (1985).
It is essential for the nonphysician mental health provider working in the primary care setting or
with primary care providers to familiarize him- or herself with the essentials of the physical and
neurological examination of the patient with headache, as well as the neurodiagnostic imaging
procedures used in the investigation of headache. Learning to at least understand what the terms
and procedures used by medical providers are may save you embarrassment later on. Understanding
the basic pharmacological treatment approaches to both migraine and vascular headache is also
useful. We would urge the nonphysician mental health provider to get a copy of what most
headache experts consider the “bible” of headache—Diamond’s and Dalessio’s The Practicing Physicians
Approach to Headache (Diamond & Solomon, 1999a)—and read the relevant chapters carefully. We
would also urge that nonphysician mental health providers purchase a medical dictionary and keep
it on their desk or at their computer for quick reference.
The psychophysiological interventions—biofeedback and relaxation therapy—can be and are
administered by many health care professionals, such as nurses, psychologists, physicians assistants,
individuals with master’s degrees in psychology, social workers, physical therapists, chiropractors,
and physicians. Generally, however, physicians assistants and physicians in a busy primary care
setting do not conduct such interventions, generally leaving it up to a nurse, physical therapist, or
mental health professional. Cognitive behavior therapy should be conducted only by a trained
mental health professional.
Nonpharmacological Outcome Results
Tension Headache
A beneficial manner of reporting outcome is the average proportion or fraction of a sample of
headache patients who achieve a clinically significant reduction in headache activity, as docu-
mented by the daily headache diary. In chronic pain, a 50% or greater reduction in pain activity is
generally considered a treatment success. With tension headache, the biofeedback approach used is
EMG (muscle tension) feedback from the forehead, neck, or shoulders. For relaxation therapy
alone, this value ranges from 40–55%, for EMG biofeedback alone, from 50–60%, and for cognitive
therapy, from 60–80%; when EMG biofeedback and relaxation are combined, the average improves
from about 50% to 75%; when relaxation and cognitive therapy are combined, success increases
from 40–65%.
Migraine Headache
For patients with pure migraine headache, hand surface temperature (or thermal) is the biofeed-
back modality of choice, and it leads to clinically significant improvement in 40–60% of patients.
Cognitive therapy by itself has about 50% success. A systematic course of relaxation training seems
to help when added to thermal biofeedback (increasing success from about 40–55%), but cognitive
therapy added to the thermal biofeedback and relaxation does not improve outcome on a group
basis. Relaxation training alone gets success in from 30–50% of patients, and adding thermal
biofeedback boosts that success (from about 30–55%).
Combined Migraine-Tension Headache

For patients with both kinds of the primary benign headache disorders (migraine and tension-type),
the results with thermal biofeedback alone are a bit lower, averaging 30–45% success; relaxation
training alone leads to 20–25% success. The best results come when thermal biofeedback and relax-
ation training are combined. With this combination treatment, results show 50–55% success rates
(adding thermal biofeedback to relaxation raises success from 20–55%; adding relaxation therapy
to thermal biofeedback increases success from 25–55%). We strongly recommend a combination of
the two treatments for these headache sufferers.
Special Headache Populations

There are a number of special headache populations for which nonpharmacological interventions
are beneficial, and two where the research has demonstrated that they are relatively ineffective.
There is now a sizable body of research attesting to the efficacy of thermal biofeedback with pediatric
migraine (see Arena & Blanchard, 2002). In addition, headaches in the elderly can also be effectively
treated with biofeedback and relaxation techniques (Arena, Hightower, & Chang, 1988; Arena,
Hannah, Bruno, & Meador, 1991; Kabela, Blanchard, Appelbaum, & Nicholson, 1989; Nicholson &
Blanchard, 1993), as can those individuals who consume excessive levels of medication (Blanchard,
Taylor & Dentinger, 1992; Michultka, Blanchard, Appelbaum, Jaccard & Dentinger, 1989). Hick-
ling, Silverman, and Loss (1990), as well as Turk and his colleagues (Marcus, Scharff & Turk, 1995;
Scharff, Marcus & Turk, 1996), have demonstrated that a combination treatment including relax-
ation therapy and biofeedback is efficacious for treating headaches during pregnancy. Because
pregnant women are not able to use most pain medications, we feel that techniques such as the
psychophysiological interventions and psychotherapy should be the first-line intervention for head-
ache during pregnancy (Marcus, 2002).
Cluster headache, which is a very rare type of headache and tends to be found predominantly in
males, is generally diagnosed by its very distinctive temporal pattern. In episodic cluster headache,
the patient is headache-free for months to years and then enters a so-called cluster bout. During the
cluster bout, the one-sided headaches appear fairly regularly, once or twice per day to every other
day. The headaches are described as intense, excruciating pain that often makes it impossible for the
patient to lie still; they last from 15–30 minutes to 2–3 hours. Many patients are so debilitated by
this type of headache that it can take hours for them to return to a normal level of functioning. The
cluster bout lasts several weeks to several months and then disappears. Some unfortunates have
continuous cluster headache. Nonpharmacological interventions have been found to be relatively
ineffective for cluster headache (Blanchard, Andrasik, Jurish & Teders, 1982) and, given these poor
results and our clinical experience, we no longer see such patients in our practice.
Blanchard and colleagues (Barton & Blanchard, 2001; Blanchard, Appelbaum, Radnitz, Jaccard,
& Dentinger, 1989) have identified a relatively refractory headache type they have labeled “chronic,
daily high-intensity headache.” Individuals with this type of headache describe their headache as
present essentially all the time (at least 27 out of 28 days) at a moderately severe to severe level of
pain and distress. Thus, although these patients usually meet the nominal criteria for tension-type
headache, their severity ratings are like those of migraine patients and show little variability. In a
retrospective case-control analysis, Blanchard et al. (1989) found that only 13% of patients
with chronic, daily high-intensity headache responded favorably to combinations of biofeedback,
relaxation, and cognitive therapy. Barton and Blanchard (2001), in a prospective study using a 20-
session intensive combination treatment, had only 17% respond favorably.
Cost Effectiveness
Treatment of chronic headache through the techniques described in this chapter by experienced
practitioners can result in considerable savings in health-care dollars over the patient’s lifetime. The
reason for this, of course, is that successful treatment of the headache problem results in a marked
decrease in physician office visits, diagnostic procedures, and prescriptions for pain medication.
One study that addressed this issue (Blanchard, Jaccard, Andrasik, Guarnieri, & Jurrish, 1985)
found that, when one compared the total medical expenses a set of chronic headache patients had
incurred in the 2 years prior to receiving nondrug therapy to the expenses for the 2 years following
nondrug therapy, the average reduction was almost 90%. In 1985 dollars, the reduction was
from an average of $200 per patient for all headache-related medical care in the 2 years prior to
treatment to approximately $25 in the 2 years following treatment. To the best of our knowledge,
formal cost-effectiveness studies have not been performed; however, these data from Blanchard and
colleagues certainly indicate a marked reduction in expenses following psychosocial treatment of
the headache.
Prevention of Chronic Benign Headache

Unfortunately, research on the prevention of chronic benign headache is in the fetal stage of devel-
opment. To our knowledge, there have been no prospective or retrospective primary, secondary, or
even tertiary prevention studies conducted. We do, however, have a research literature base from
which the careful clinician or researcher can make logical inferences that may enable a mental
health professional to assist in educating the primary care provider to identify individuals who may
be at elevated risk for headache. The primary care provider may be able to either prevent headache
from occurring or stop headaches in the early stages, averting them from becoming a significant
health problem.
The strongest evidence suggesting that prevention may be possible comes from the epidemiological
literature, which has repeatedly demonstrated that migraine, as opposed to tension or cluster
headache, is a familial and possibly hereditary illness:
If both parents have experienced migraine, there is a 70% chance that the children will also
have migraine; if only one parent has had migraine, the children’s chances are reduced to
about 45%. If neither parent has had migraine but there is a history of migraine in other family
members, it will occur in about 25% of the children (Diamond & Solomon, 1999b, pp. 20–21).
Given this strong familial pattern, we advance that it would be prudent to inform all migraine
patients that their children ought to be carefully observed and brought in to the primary care clinic
at first signs of a headache problem. Parents should also be instructed to be particularly sensitive in
detecting certain psychological characteristics that may be harbingers of future headache problems,
especially depression (see below), and to seek early intervention should they occur. In very young
children (preschool), the presence of nausea may be a precursor of migraine headache. The mental
health professional may wish in his or her communications with primary care providers to suggest
that they routinely pursue a similar course of education and prevention with their migraine
patients.
It has long been known that there is a relationship between headache and depression and that
both are significant primary care problems. In a recent large-scale study (Wu, Parkerson, &
Doraiswamy, 2002) it was found that primary care patients with high levels of anxiety or depression
had nearly double the amount of headaches of those with lower levels (4.4 versus 2.3). In an impor-
tant study, Breslau et al. (2000) examined the relationship between headache and major depression
by eliminating the risk for the onset of major depression in persons with prior migraine and the
risk for onset of migraine in persons with prior major depression. Unfortunately, this study was
confounded by including tension headache subjects in a nonmigraine group, which they termed
“severe headache” (59% of the severe headache group was composed of tension-headache subjects);
however, their findings certainly hold for migraine headache. Results indicated a lifetime prevalence
of major depression of 49% for those migraineurs with auras, and 37% for migraineurs without
auras; the severe headache group (composed mostly of tension headache) had a 36% lifetime
prevalence for major depression, and the nonheadache controls had a 16% lifetime prevalence. The
authors found a bidirectional relationship between migraine and depression:
Migraine signaled an increased risk for the first onset of major depression, and major depres-
sion signaled an increased risk for the first time occurrence of migraine. … In contrast, severe
headache signaled an increased risk for major depression, but there was no evidence of a
significant influence in the reverse direction, from major depression to severe headache
(Breslau et al., 2000, p. 311).
Given this relationship between headaches and depression, there are a number of strategies the
mental health professional can take to assist the primary care provider in preventing headaches and
in preventing depression in headache patients (see chapter 17 by Callaghan, Ortega, and Berlin, this
volume) for prevention of depression in primary care. We have focused in this chapter on strategies
especially relevant to headaches and depression.
All patients who have headaches should be carefully assessed for depression and treated accord-
ingly. Often, headache patients—especially migraineurs and chronic, daily high-intensity headache
sufferers—stay around the house mostly and engage in few pleasurable events in their lives. As a
result, they become significantly depressed, which increases their pain levels and starts a vicious
pain-depression cycle. If no or very low levels of depression are present, we have found that the
primary care provider cautioning pain patients not to isolate themselves, to maintain normal inter-
actions with family and friends, and continue engaging in pleasurable events is generally much
more effective in preventing depression than a mental health professional stating the same concerns.
If moderate to severe depression is found, cognitive behavioral therapy and/or pharmacological
intervention is warranted. Given the fact that high levels of depression have been shown to lead to
poorer psychophysiological treatment outcome (Andrasik et al., 1982; Arena & Blanchard, 2000;
Blanchard, Andrasik & Arena, 1984; Blanchard, Andrasik, Neff et al., 1982), we would suggest that, if
possible, the depression should be treated prior to the onset of such treatments. Finally, although
exercise can bring on some types of headache, and there is even a rare form of headache termed
benign exertional headache (Kunkel, 1999), anecdotally we have found that exercise is often extremely
helpful in treating depression in headache patients, as it has in the general depressed population
(Blumenthal, Babyak, Moore, Craighead, & Herman, 1999). After obtaining medical approval, we
routinely suggest that our headache patients engage in a regular exercise regimen. Often this is as
simple as walking briskly (3–4 miles per hour) for 30 minutes three to four times a week.
Given the fact that both depression and migraine are familial illnesses, the mental health profes-
sional may wish to communicate to their migraine patients that their children should be carefully
observed and brought in to the clinic if they evidence early signs of depression. Other emotions
have been implicated in headache, such as anxiety and obsession (Arena, Blanchard, Andrasik, &
Applebaum, 1986; Arena, Andrasik, & Blanchard, 1985; Arena, Blanchard, & Andrasik, 1984;
Blanchard et al., 1984) and anger (Arena, Bruno, Rozantine, & Meador, 1997; Ham, Andrasik,
Packard, & Bundrick, 1994), although the relationship is not as clearly demonstrated as that of
depression, and clinicians may wish to communicate this information to their headache patients, as
well as to primary care providers.
Dietary Factors in Prevention

It is reasonably well recognized (for a detailed account see Diamond and Dalessio, 1999) that in
some individuals with migraine headache, the headaches are triggered by certain foods. Some of the
common food triggers are chocolate and tyramine-containing substances, such as red wine, aged
cheese, and alcohol. It thus becomes possible to prevent these food-triggered migraine headaches
by eliminating those foods from the patient’s diet. As a first step, the primary care physician might
inquire if the patient has ever noticed any association between eating certain kinds of food or
drinking certain kinds of beverages and developing a migraine headache in the next day or two.
A list of potential food triggers can be found in Diamond and Dalessio (1999). This list could also
be given to the patient. The patient will have to perform the experiments on him- or herself to see
whether he or she has a food sensitivity that triggers migraine headache. However, in our experi-
ence, just mentioning this idea causes an awakening of potential associations in certain patients.
More details on an empirical approach to the use of elimination diets and food testing can be found
in articles by Radniz, Blanchard, and Bylina (1990) and Radnitz and Blanchard (1991). In the first
paper, individuals who proved refractory to intensive psychosocial treatments were led through
elimination diets and food challenges to identify which foods caused their headaches. Elimination
of those foods from the diet then had a profoundly positive effect on their headache intensity,
frequency, and duration.
There is data to suggest that migraines may be highly correlated to a high-fat diet. Bic, Blix,
Hopp, Leslie, and Schell (1999) had 54 migraine subjects monitor their food intake for 28 days and
then restricted their fat intake to no more than 20 grams a day. “Subjects significantly decreased
their ingestion of dietary fat in grams between baseline (mean 65.9 g/day, p < 0.0001) and the
postintervention period (mean 27.8 g/day). The decreased dietary fat intervention was associated
with statistically significant decreases in headache frequency, intensity, duration, and medication
intake (all p < 0.0001). There was a significant positive correlation between baseline dietary fat
intake and headache frequency (r = .44, p = 0.02)” (p. 623). Thus, a low-fat diet can reduce head-
ache frequency, intensity, and duration, and medication intake.
Changing an individual’s eating habits and asking him or her to eliminate certain foods can be a
very difficult task for the patient to carry forward. Consultation with a registered dietician may be
needed to help the patient in this area.
Summary
In this chapter we have reviewed the basics of nonpharmacological treatments for migraine and
tension-type headache, placing special emphasis on the frontline mental health professional in a
primary care setting. We hope we have demonstrated that the application of psychological con-
structs to chronic pain disorders is simple and straightforward, that effective nonpharmacological
treatments are now well established for headache and do not require a great deal of specialized
training, and that the mental health professional can easily apply such skills to traditional medical
domains such as pain. Collaborative efforts between the mental health professional and primary
care provider will likely lead to more positive outcomes in headache treatment.
Acknowledgment
This chapter was supported by a Department of Veterans Affairs Merit Review awarded to John
G. Arena, and by National Institute of Mental Health Grant No. MH-41341 awarded to Edward
B. Blanchard.
Appendix A Headache Diary
Date Diary Started: ______/______/______

Last 4 digits of social security: __________________ Phone # ______________
Please record:
(1) Headache Pain (0–10 scale; see Pain Rating Scale for details)
(2) Stress Level (0–10 scale: 0 = no stress 10 = most stress I have ever had)
(3) Pain Medication (A–J; see Pain Medication List)
Time of Day Day of the week SU M TU W TH F S

B Headache Pain Level (0–10)
R
E
A Stress Level (0–10)
K
F
A Medication Code (A–J)
S
T
L Headache Pain Level (0–10)
U
N Stress Level (0–10)
C
H Medication Code (A–J)
D Headache Pain Level (0–10)
I
N Stress Level (0–10)
N
E Medication Code (A–J)
R
B Headache Pain Level (0–10)
E
D Stress Level (0–10)
T
I Medication Code (A–J)
M
E
Best estimate of total # of hours of pain
APPENDIX A (continued)
Pain Rating Scale:
0 = No Pain
2 = Mild Pain: aware of it only when paying attention to it
4 = Mild Pain: can be ignored at times
6 = Moderate Pain: pain is noticeably present
8 = Severe Pain: difficult to concentrate, but can do undemanding tasks
10 = Intense Pain: excruciating, intolerable, or incapacitating pain
Pain Medication List

Please record pain medication information and transfer the letter A–J to the Headache Diary.
Examples: A Tylenol 2 tablets 500 mg acetaminophen
B Percocet 1 tablet 325 mg acetaminophen, 5

mg oxycodone
C Imitrex 1 injection 6 mg sumatriptan succinate
Medicine Brand Name Of Medication Quantity Dose (mg) and Type of drug
Code in each tablet (or injection)
A
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Chapter 16
Addressing Chronic Pain in Primary
Care Settings
RICHARD C. ROBINSON, MARGARET GARDEA, ANN MATT

MADDREY, AND ROBERT J. GATCHEL
Chronic pain is a devastating condition that impacts virtually all areas of a person’s life. Despite the
distinct symptoms of different chronic pain disorders (e.g., fibromyalgia, postherpetic neuralgia,
musculoskeletal pain, etc.), all share the central symptom of pain, which often leads to emotional
suffering. Our knowledge of these different disorders continues to grow; however, chronic low back
pain (CLBP) remains the condition about which we know the most and provides us with a starting
point to discuss chronic pain conditions in general. An estimated 70–80% of adults will suffer from
a spinal disorder at some point during their lives, but the majority of these spinal disorders (90%)
will resolve within 6 months of onset (Deyo, Cherkin, Conrad, & Volinn, 1991; Lanes et al. 1995).
In addition, 15% of the U.S. population is totally and permanently disabled by chronic spinal disor-
ders (Gatchel, Polatin, & Mayer, 1995). In a more recent study, Linton, Hellsing, and Hallden
(1998) reported a 1-year prevalence of 66% for musculoskeletal pain in persons 35–45 years of age.
More alarming, 25% of those individuals reported significant pain and disability.
The costs of chronic pain are staggering. An estimated 80% of physician visits are related to pain
disorders (Gatchel & Epker, 1999). With regard to spinal pain patients, approximately $16 billion is
spent annually on treatment (Holbrook, Grazier, Kelsey, & Stauffer, 1984), and with regard to all
musculoskeletal pain patients, $27 billion is spent annually (Gatchel et al., 1995). When other costs
associated with disability (e.g., social security, lost productivity, etc.), are included with the treat-
ment costs, $20–60 billion is lost annually to musculoskeletal disorders (Mayer & Gatchel, 1988).
Psychosocial factors play an important role in the perception and reporting of pain. Engel in
1959 postulated that certain personality characteristics might predispose an individual to chronic
pain. He believed that factors, such as a history of defeat in one’s personal life, significant guilt, and
unsatisfied aggressive impulses might place a person at greater risk. Melzack and Wall’s (1965) Gate
Control Theory of pain provided a conceptual framework for the role of higher cognitive processes
in the perception of pain. These researchers proposed that a neurophsyiological “gate” was located
in the dorsal horn of the spinal column and that both ascending and descending nerve fibers
influenced the gate. At the dorsal horn, afferent peripheral signals could be modified by signals
315
originating in the higher cortical regions, increasing or decreasing the final peripheral signals that
reached the brain.
With the advent of the Gate Control Theory of pain, our conceptualization of pain moved from
the biomedical model to the biopsychosocial model. Chronic pain has defied traditional biomedical
explanations, because the amount of tissue damage frequently failed to coincide with the amount of
reported pain. Although Engel first suggested the biopsychosocial model, Turk and Rudy (1987)
elaborated upon it so that it could be applied to chronic pain. Their model considered the cognitive,
affective, psychosocial, behavioral, and physiological components of pain so that the entire person
could be understood. In addition, according to their model, the role that psychosocial factors play
increases as suffering increases, which, in turn, increases pain behavior and causes additional suffering.
At this point it may be helpful to note the qualitative distinction between acute and chronic
pain. According to Grzesiak (1991), acute pain serves as a biological signal. The clinician deter-
mines the somatic cause and is assisted with the appropriate interventions based on the location,
pattern, and description of the pain. In contrast, according to the biopsychosocial model, chronic
pain serves a different function altogether. Rather than assisting by pinpointing a causal somatic
problem, chronic pain serves as a signal to the health-care professional that something is wrong
somewhere in the patient’s life. The origin of these problems may be biological, psychological, or
social in nature.
Psychosocial Factors
Several excellent review articles and chapters have been written concerning psychosocial factors
associated with chronic pain that place individuals at risk for developing chronic pain (Gatchel &
Epker, 1999; Mayer & Gatchel, 1988). However, at this time, no one variable or set of variables can
accurately predict who will go on to develop a chronic pain condition. Several of the most impor-
tant and well-researched psychosocial variables will be briefly touched upon in this chapter.
Psychopathology
Although we have come to understand that a host of psychosocial variables place a patient at risk
for developing chronic pain, the presence of psychopathology, and specifically depression, has
received thorough investigation. Numerous studies have found rates of major depression in chronic
pain patients that exceed those found in the normal population. In CLBP patients, current rates of
45% and lifetime rates of 65% have been found. In upper-extremity patients, even higher rates have
been reported (i.e., 80% for current and lifetime; Kinney, Gatchel, Polatin, Fogarty, & Mayer, 1993;
Polatin, Kinney, Gatchel, Lillo, & Mayer, 1993). These figures stand in stark contrast to the occur-
rence of depression in the normal population, which is 5% current and 17% lifetime (American
Psychiatric Association, 1987).
Fishbain, Cutler, Rosomoff, and Rosomoff (1997) explored the relationship between pain and
depression through a meta-analysis of 23 studies. They found that 21 studies reported an association
between the intensity of pain and the degree of depression. Further, other studies reviewed found
associations between pain duration and the development of depression, between pain frequency
and depression, and between the number of pain sites and depression. The relationship between
pain and depression exists, but the nature of the interaction has only begun to be understood.
The relationship between pain and depression is far from simple. Several studies have looked at
interactions among pain, depression, and other demographic and work variables. Averill, Novy,
Nelson, and Berry (1996) studied 254 chronic pain patients and found a significant negative
relationship between work status and depression in chronic pain patients. Further, Magni, Moreschi,
Addressing Chronic Pain in Primary Care Settings • 317
Rigatti-Luchini, and Mersky (1994) also found that unemployment was associated with depression.
Complicating matters further, these investigators reported a relationship among depression, age,
and gender in chronic pain patients. Younger women appear more depressed than younger men, and
older men appear more depressed than older women (Magni et al., 1994). Further, other investiga-
tors reported that working chronic pain patients who planned litigation had higher levels of depres-
sion than working patients who were not planning litigation (Tait, Chibnall, & Richardson, 1990).
The recognition and treatment of depression is an important goal in and of itself. However,
addressing depression in chronic pain patients is a clear necessity for appropriate treatment of their
pain. Weickgenant et al. (1993) demonstrated that CLBP patients who are depressed avoid activities
and social support and engage in more self-blame than those patients who are not depressed.
Dworkin, Handlin, Richlin, Brand, and Vanucci (1986) demonstrated that depressed chronic pain
patients were less likely to benefit from treatment. Haley, Turner, and Romano (1985) found that
antidepressant medication given to pain patients resulted in lowered self-reports of pain, and other
researchers have found that patients who are depressed have lowered pain tolerances and a propen-
sity to magnify symptoms (Averill et al., 1996). Obviously, patients who are depressed are going to
be less likely to engage in a number of activities that would help them with their pain, such
as actively engaging in physical therapy, resolving workers’ compensation issues, and practicing
relaxation management techniques.
Depression is not the only form of psychopathology that has been associated with chronic pain.
Polatin et al. (1993) used the Structured Clinical Interview for the Diagnostic and Statistical Manual
of Mental Disorders-III-Revised and reported that 77% of CLBP patients met lifetime diagnostic
criteria for a psychiatric disorder. These researchers found the highest rates for depression,
substance abuse, and anxiety disorders. Further, 51% of the patients they examined met diagnostic
criteria for a personality disorder.
When discussing pain and depression, or pain and psychological distress, the question often
arises, Which came first, the pain or the psychopathology? Unfortunately, there is no simple answer,
but this question continues to receive a great deal of attention. Several studies have attempted to
examine this question by looking at the difference between acute and chronic pain patients, as well
as looking at patients before and after successful treatment. Sternbach, Wolf, Murphy, and Akeson
(1973) examined the Minnesota Multiphasic Personality Inventory (MMPI) profiles of acute and
chronic pain patients and reported that chronic pain individuals were more distressed as measured
by the first three clinical scales of the MMPI (Scale 1 Hypochondriasis; Scale 2 Depression; and
Scale 3 Hysteria; also known as the “neurotic triad”). Barnes, Gatchel, Mayer, and Barnett (1990)
reported that MMPI profiles in chronic pain patients reporting distress returned to normal levels 6
months after successfully competing an intensive 3-week functional restoration treatment program.
Gatchel (1991) attempted to clarify this complex relationship between pain, psychopathology,
and personality by theorizing about the progression from of acute to chronic pain. He refers to the
psychological changes that occur as a person progresses from acute to chronic pain as a “layering of
behavioral/psychological problems over the original nociception of the pain experience itself ”
(p. 34). His model is based on a three-stage progression from acute to subacute to chronic disability
following the experience of pain as a result of an identifiable injury. Stage 1 encompasses the result-
ing emotional reactions (e.g., fear, anxiety, and worry) that arise as a consequence of perceived
pain. Stage 2 begins when the pain persists past a reasonable, acute time period. It is at this stage
that the development or exacerbation of psychological and behavioral problems occurs. Gatchel
(1991) notes that the form these difficulties take depends primarily on the premorbid personality
and psychological characteristics of the individual (i.e., a diathesis), as well as current socioeconomic
and environmental stressors. For instance, an individual with a tendency to become depressed may
develop a depressive disorder in response to the economic and social stress of being unable to work
as a result of pain (Gatchel & Turk, 1996). Weisberg, Vittengle, Clark, Gatchel, and Garen (2000)
have also recently amplified such a “diathesis-stress” model.
This complex interaction of physical and psychosocioeconomic factors leads to Stage 3 of the
model. As the patient’s life begins to totally and completely revolve around the pain as a result of
the chronic nature of the problem, the patient begins to accept the sick role. By doing so, the patient
is excused from normal responsibilities and social obligations, which may serve to reinforce the
maintenance of the sick role (Gatchel, 1991).
Further adding to the “layers” of behavioral and psychosocial difficulties is the addition of phys-
ical deconditioning, which generally accompanies patients during their progression toward chronic
disability. The physical deconditioning syndrome generally leads to the progressive lack of use of
the body, as when an individual is physically and emotionally distressed. Research has shown that
this physical deconditioning can produce a circular effect, leading to increased mental deconditioning.
The combined interaction of the symptoms as they reinforce one another negatively impacts the
emotional well-being and self-esteem of an individual. Conversely, these same negative emotional
reactions can reinforce the physical deconditioning through decreased motivation to participate in
work and recreational activities. Further complicating the process, when patients engage in an
activity that produces acute pain, they are likely to associate the pain with the initial hurt. This
causes patients to fear and avoid pain and possible pain-producing situations (Gatchel & Turk,
1996). Unfortunately, pain often accompanies physical reconditioning and the additional steps
needed in order to resume normal responsibilities and social obligations. Therefore, patients must
be taught that hurt and harm are not the same (Fordyce, 1988).
Coping
An increasing area of interest concerns how a person copes with the stress often associated with
chronic pain. The Multidimensional Pain Inventory (MPI), formerly the West-Haven Yale Multidi-
mensional Pain Inventory, developed by Kerns, Turk, and Rudy (1985) is a widely used measure in
the pain area that examines a person’s perception of his or her pain and coping ability. Turk and
Rudy (1988) found three types of coping styles on the MPI in chronic pain patients: dysfunctional
(43%), interpersonally distressed (28%), and adaptive copers (29.5%). The dysfunctional group
members reported extreme pain and interference from their pain in their lives. Patients in the inter-
personally distressed group indicated that they perceived a lack of support and understanding from
important individuals in their lives. Adapative copers reported high levels of activity and lower
levels of pain, interference in their lives from pain, and affective distress.
Epker, Gatchel, and Ellis (1999) used the MPI in temporomandibular patients and found that
either dysfunctional or interpersonally distressed profiles on the MPI had more biopsychosocial
difficulties than patients with adaptive coper profiles. In addition, Brown and Nicassio (1987)
found an association between decreased pain and coping strategies that were more active, rather
than passive, in nature, such as staying busy and using distraction techniques.
A specific maladaptive coping strategy or response to stress that has received increasing empirical
scrutiny is catastrophizing. Catastrophizing is said to occur when a person has exaggerated, negative
cognitions about events and stimuli. For instance, a patient who has pain that has lasted 9 months
may catastrophize by thinking to him- or herself, “This is the worse thing that has ever happened
and I will never get better.” Butler, Damarin, Beaulieu, Schwebel, and Thorn (1989) found that
catastrophizing was associated with higher levels of pain in patients who had undergone surgery.
Jacobsen and Butler (1996) studied 59 females who underwent surgery for breast cancer and found a
positive relationship between catastrophizing and pain as well as between catastrophizing and analge-
sic use. Sullivan, Stanish, Waite, Sullivan, and Tripp (1998) found that catastrophizing was positively
related to disability, pain, and unemployment. Interestingly, they found that catastrophizing was
related to disability independent of the level of anxiety or depression.
Occupational Functioning
Job satisfaction is an especially important variable associated with pain and disability. Both retro-
spective (Bigos et al., 1986) and prospective (Bigos et al., 1991; Cats-Baril & Frymoyer, 1991; Croft
et al., 1995) studies have found an association between pain and job satisfaction. That is, low job
satisfaction appears related to increased pain and disability. Williams and colleagues (1998) found
that job satisfaction may help prevent patients from progressing from acute to chronic pain, and
that job dissatisfaction may increase the chances of long-term disability. As with many risk factors,
there are important interactions with other demographic variables. For instance, Vingard and
colleagues (2000) found that job dissatisfaction increased the risk of low back pain in males, but not
in females.
Often related to the area of work and job satisfaction is the notorious topic of secondary gain.
Secondary gain includes factors such as potential monetary gain, avoidance of work duties, or
avoidance of social and familial responsibilities. Primary care physicians should be aware that
secondary gain issues might inadvertently reinforce the patient’s pain. Research suggests secondary
gain may serve as a powerful disincentive and barrier to recovery.
Perhaps one of the most powerful secondary gain factors is monetary compensation. Many studies
have found that patients with compensation cases have poorer outcomes than patients without any
such issues. The presence of active compensation has shown a significant impact on the continu-
ance of disability (Beals, 1984). Rohling, Binder, and Langhinrichsen-Rohling (1995) found a
relationship between compensation and increased pain and decreased treatment efficacy. Another
study found that the most robust predictor of poor postoperative outcome was the presence of
pending litigation associated with a workers’ compensation disability claim (Vaccaro, Ring, Scuderi,
Cohen, & Garfin, 1997). A study of a large U.S. worker sample was undertaken by Gatchel et al.
(1995). The researchers followed 421 acute low back pain patients for 1 year. Logistic regression
analyses discriminated between employed subjects versus those not working due to their original
back injury. Workers’ compensation and personal injury insurance status were one of the four
psychosocial variables found to play a role in the development of a chronic pain condition and to
contribute to unemployment status. Rainville, Sobel, Hartigan, and Wright (1997) found subjects
in the compensation group reported a greater amount of pain, depression, and disability than the
individuals without compensation involvement. Overall, these findings suggest that given the same
physical symptoms, patients with compensation issues may not interpret their improved physical
capacity as impacting their daily functioning compared with to noncompensation patients. It is
possible that the reinforcing nature of the secondary gains received from their compensation
involvement may result in the reluctance of patients to report significant improvement.
On the other hand, further research has found that compensation in itself may not be a barrier
to outcome. Rainville et al. (1997) recognized that in their study, compensation patients had more
severe chronic back pain syndromes and, therefore, depict a more complex challenge for the treating
physician. Sanderson, Todd, Holt, and Getty (1995) suggest that employment status may influence
disability more than compensation. In general, the investigators found that the presence
of compensation and unemployment resulted in higher disability scores. However, when patients
receiving compensation were analyzed according to employment status, notable differences
were found. Patients who were still working had significantly less disability when compared with
those who remained unemployed. The authors conclude that while both unemployment and com-
pensation status impact disability, the most important factor appears to be employment status.
Finally, Ambrosius, Kremer, Herkner, DeKraker, and Bartz (1995) evaluated 60 back pain patients
enrolled in a functional restoration program. Subjects were divided into two groups according to
their compensation-seeking status. A high return-to-work frequency was achieved for both groups.
Overall, 91% of the compensation-seeking subjects and 100% of the noncompensation group
returned to employment.
Although the research on secondary gains is mixed, the variables underlying this relationship are
only beginning to be understood. The majority of the evidence demonstrates a powerful impact on
outcome. Preliminary research has established a relationship between compensation and decreased
treatment efficacy and productivity, in addition to increased reported pain levels, depression, and
disability. Primary care physicians working with chronic pain patients must identify secondary gain
issues that may impede treatment. Once recognized, the physician should work together with the
psychologist to address the matter with the patient.
Assessment
To properly assess a chronic pain patient, one must understand the biopsychosocial aspects of the
patient. Several instruments have been developed that serve to answer these questions. A list of
these instruments is provided here so the primary care physician can become familiar with the most
common ones in use. However, administration and interpretation of these instruments should be
limited to those individuals who have been trained to integrate data from various sources.
Minnesota Multiphasic Personality Inventory (MMPI-2). The MMPI-2 is a 567-item, self-

report questionnaire that provides information on psychiatric symptoms and personality
organization. Internal consistency typically ranges from .60 to .90, depending on the
specific scale and population being tested (Graham, 1993). This instrument provides a
wealth of information, but often takes pain patients several hours to complete and must be
interpreted by an individual who has received specialized training.
Structured Clinical Interview for DSM-IV–Nonpatient Version (SCID-NP). The SCID-NP is a
highly structured interview that yields diagnoses corresponding to the criteria within the
DSM-IV. It has been shown to have moderately high reliability for both current and
lifetime Axis I diagnoses, with kappa coefficients of .61 for current diagnoses and .69 for
lifetime diagnoses (Spitzer & Williams, 1986). The SCID represents the gold standard
for psychiatric diagnosis, but requires training in administration and can be fairly
time consuming.
Hamilton Rating Scale of Depression (HRSD). The HRSD is a clinician-administered rating
scale that consists of 17 items, with total scores ranging from 0 to 50. In a previous study,
the interrater reliability has been found to be adequate (Rush, Beck, Kovacs, & Hollon,
1977). This is a fairly easy instrument to learn to administer, and it takes only a few min-
utes to complete.
Beck Depression Inventory (BDI). The BDI is a self-report measure containing 21 items related
to physical and emotional symptoms of depression and is currently one of the most widely
used measures of depression in both medical and psychological research. It was developed
by Beck, Ward, Mendelson, Mock, and Erbaugh (1961) in order to offer a reliable and
valid measure of the presence and severity of depression. This is a frequently used self-
report measure of depression that takes a patient only a few minutes to complete.
The Dallas Back Pain Questionnaire (DBPQ). This analogue scale is a 15-item, self-report
questionnaire containing items related to pain and disability. Subjects indicate their
response to each question by picking a point on a 10-cm line representing a range of possible
answers from 0 to 10. For instance, endpoints of the scale may signify: “No Problems” and
“Totally Cannot Work” for questions related to disability. Million, Haavik-Nilson, Jayson,
and Baker (1981) developed the scale and validated it through correlation with clinicians’
findings. The total score is the sum of all responses. Scores of 0 to 39 indicate “mildly
disabling” pain, 40 to 84 indicate “moderately disabling pain,” and 85 and above indicate
“severely disabling pain.” The Dallas Pain Questionnaire has particular utility when the
self-report of pain exceeds what would be expected given physical findings. This finding
might suggest the existence of a psychosocial component in the patient’s disability (Capra,
Mayer, & Gatchel, 1985).
The Multidimensional Pain Inventory (MPI). The MPI is a brief, self-report pain inventory
theoretically based on the cognitive behavioral perspective of evaluating and managing
pain. It was normed on chronic pain patients. Eight scales are provided to determine
patient perception of pain, and three clusters can be determined according to patient
coping style (adaptive, interpersonally distressed, and dysfunctional). Internal consistency
reliability estimates range from .70 to .90 for the different scales. Stability estimates range
from .62 to .91. Adequate validity was determined through correlation with a variety of
measures related to the different MPI scales (Kerns et al., 1985). Again, this is a quick and
easy test to administer.
One question frequently asked by practitioners is “What is the best assessment test to use with
my pain patients?” There is no single answer to this question, because the question itself needs to be
prefaced by various more specific questions, such as: For what purpose is the assessment being
performed (e.g., comprehensive patient management/treatment planning; surgical prescreening
determination; palliative care, etc.)? Is the assessment purely for clinical purposes or for treatment
outcome documentation purposes? Is there a health-care specialist available to help with integrating
the assessment test results? The first of these more specific questions is the most-often asked.
In answering the question, What is the best battery of assessment tests to use for comprehensive
patient management/treatment planning? Gatchel (2000) has recommended a stepwise approach
where one chooses the most time- and cost-effective biopsychosocial assessment of patients.
Of course, one must not make the assumption that there is a single instrument that can serve as the
best assessment method. For most patients, several assessment methods will be needed. Rather than
asking what method should be used, a better question is, What sequence of testing should I consider
to develop the best understanding of potential biopsychosocial problems that might be encountered
with the patient? With a stepwise approach, briefer instruments are administered initially and more
thorough assessment instruments are used only with patients who appear to be experiencing more
complex psychosocial problems as assessed by briefer measures or interview data. In addition,
collecting psychosocial data requires staff who are appropriately trained to interpret and make
appropriate referrals when needed, such as a psychologist or other mental health-care professional.
In addition to the above measures, approaching chronic pain patients from a biopsychosocial
perspective will allow one to intuitively understand which questions to ask. For instance, in
addition to questions related to physical symptoms, questions about their mood and the impact
pain has had on their lives would provide excellent information. Many primary care physicians will
often ask these questions when time permits. However, an often-overlooked area is patients’
occupational functioning and their feelings about their jobs. Questions about their workers’
compensation status as well as any ongoing litigation may also be of great benefit.
At this time, no widely used or accepted screening instruments exist to assess the potential for
opioid abuse in chronic, nonmalignant pain patients. Fortunately, investigators such as Chabal,
Erjavec, Jacobson, Mariano, and Chaney (1997) have attempted to remedy this situation by developing
a “prescription abuse checklist” that consists of five criteria:
1. A focus on opiate issues during clinic visits impeding progress with other treatment issues
and persisting beyond the third appointment.
2. A pattern of early refills or escalating drug use in the absence of any clinical change.
3. Multiple phone calls or visits about opiate prescriptions.
4. A pattern of prescription “problems” (lost, spilled, stolen, etc.).
5. Supplemental sources of opiates.
Further, Compton, Darakjian, and Miotto (1998) developed a 42-item questionnaire based on
the criteria developed by the American Society of Addiction Medicine. These researchers found that
nonaddicted patients did not use multiple prescription providers, use illegal sources for medica-
tion, or use others’ medication. Three items correctly classified 92% of the cases: (a) a tendency
to increase opioid dose and use, (b) having a preference for route of administration, and (c) consid-
ering oneself addicted.
Treatment
Traditionally, primary care treatment for chronic pain patients has focused on eliminating
the physical pathology. The rational being that once the pain is taken care of, the other common
complaints such as lack of sleep, nervousness, and work-related difficulties will no longer exist.
However, as we have discussed earlier in this chapter, solely addressing the physical pathology is
insufficient and will likely result in poor outcome. Consequently, many chronic pain patients go
from doctor to doctor in an effort to find a “cure” for their pain (Turk & Gatchel, 1999). Moreover,
both physician and patient often experience increased frustration over the patient’s lack of
improvement, given the repeated efforts.
Chronic pain is best conceptualized as an ongoing, long-term, dynamic condition with recipro-
cal interplay between the patient’s biological, cognitive, affective, behavioral, and social factors
(Dworkin, Von Korff, & LeResche, 1990). As mentioned earlier, chronic illness is a debilitating,
demoralizing, and often overwhelming condition that drastically impacts all aspects of the patient’s
life. Effective treatment, therefore, must address all components—biological, psychological, and
social aspects—of the illness.
Ideally, an interdisciplinary approach is the best paradigm to properly assess, conceptualize, and
treat individuals suffering from ongoing pain conditions. The International Association for the
Study of Pain (IASP) identifies an interdisciplinary clinic as a facility with a diverse group of health-
care professionals comprising of physicians, psychologists, nurses, physical therapists, occupational
therapists, case managers, and other specialists. In this setting, the health-care providers work as a
team and offer various therapeutic assessments and interventions (Loeser, 1991). Table 16.1
presents a list of standard interdisciplinary-treatment team members. The primary care physician is
capable of serving as the team leader and, therefore, is responsible for all related medical issues
associated with the patient’s pain. Given the extensive nature of this list, one will have to decide
which health-care professionals are essential in attaining the treatment goals for each patient.
In assembling a group of health-care workers, one must consider several factors. First, it is
extremely important that the primary care physician find team members who share the same
rehabilitative philosophy. For instance, many times a physician will order physical therapy for a
patient, intending him or her to receive a specialized active-oriented intervention such as functional
restoration therapy. However, the physical therapist may practice a passive mode of treatment
or provide a standard “shake-and-bake” intervention that is not necessarily suited to the patient’s
specific needs. Thus, the execution of the treatment plan is inconsistent, and the health-care profes-
sionals are striving for conflicting goals. As a result, the treatment outcome will likely be poor.
TABLE 16.1 Interdisciplinary Treatment Team Members

Physician/Medical director. Team leader; responsible for all medical matters related to complaints of pain
including diagnoses and management of physiological, anatomical, and pathological processes.
Nurse. Plays a crucial role in obtaining patient histories, assessing patients’ lifestyle, and identifying issues
that may impact response to treatment, monitor medications.
Psychologist. Aids in treatment planning with psychosocial evaluations including personality,
psychopathology, social support, level of motivation, and coping resources. In treatment, addresses and
monitors these issues.
Physical Therapist. Performs a comprehensive musculoskeletal assessment of reflexes, sensation, neurological
indices, range of motion, gait, and postural abnormalities. Once completed, tailors a program specifically
for the patient’s needs.
Occupational Therapist. Serves as a link between injured workers and their employer to help ensure needed
job modifications. Makes pre- and posttreatment evaluations focusing on the patient’s daily activities,
including work and recreational activities and the patient’s body mechanics and energy conservation.
Oversees the incremental increase of functional activity to facilitate the utmost normal level of activity for
the patient.
Medical Disability Case Manager. Typically a vocational rehabilitation professional or an occupational
therapist serves in this capacity. Monitors the patients overall progress including adherence, performance,
and posttreatment development. Also promotes vocational and social reactivation throughout treatment,
and addresses occupational planning, sequencing, and socioeconomic issues.
Second, it is imperative for all team members to recognize the importance of properly addressing
each treatment area. This includes tackling the psychological and social issues as well as the physical
pathology. One common error is to neglect the importance of psychosocial variables, especially
when there is a clear pathology such as a ruptured disk. On the other hand, physicians are quick to
remember the psychological aspects of pain whenever functional disability exceeds what is to be
expected given the physical pathology. Turk (1996) notes it is crucial to address all the facets of the
biopsychosocial model. Specifically, he states that as an illness progresses, each model component
may be weighted differently. For example, in the early stage of illness, biological aspects may domi-
nate; however, as the syndrome progresses, the psychological and social factors may come to the
forefront. Still, when a clear-cut physical pathology is present, it is tempting to treat the chronic
pain patient with a single modality such as medications, surgery, or physical therapy. Nevertheless,
it is crucial to address all the issues and not choose one single treatment over another, be it medica-
tion, psychological intervention, or physical therapy. “No single factor in isolation—pathophysio-
logical, psychological or social—will adequately explain chronic pain status” (Gatchel & Turk, 1996,
p. 7). Consequently, owing to the encompassing nature of ongoing illness, all chronic pain patients
will benefit from a comprehensive multidisciplinary intervention, not just a few. In order to prop-
erly address these psychosocial issues, the primary care physician will want to work carefully with a
health psychologist or rehabilitation counselor properly trained in psychological assessments,
behavioral interventions, and stress management.
Third, one must work carefully with the patient to explain the importance of all aspects of
multidisciplinary treatment. Because the treating physician often has increased power to influence
patients, he or she is in a unique position to organize and highlight the importance of adhering to
the complete program, not just certain aspects. For example, patients are often hesitant to see
a psychologist. If the patient refuses, the primary care physician must be emphatic and must
adequately explain to the patient that all components are integral to his or her well-being. Making
the next doctor’s appointment contingent on completing the behavioral medicine assessment may
solve this compliance problem. (Additionally, assuring patients that you know their pain is real and
not in their head, and that you don’t think they are crazy may also help.) In doing this, the physi-
cian conveys the importance of each treatment component to the patient.
Finally, and perhaps most important, frequent communication among health-care providers is
essential. The constant communication helps ensure consistent treatment interventions and philos-
ophies as well as improved patient adherence. Moreover, any conflicting information reported by
the patient, or attempts to “split” the staff, can be handled in a straightforward manner. Many
chronic pain patients are skillful at splitting clinicians. A typical example of this is when the patient
provides team members with inconsistent information (“Doc, physical therapy was really hard on
me today; my pain is excruciating and the physical therapist thinks I need more medicine”). Pitfalls
such as this can be avoided with an interactive team approach.
Gatchel and Turk (1999) have outlined the essential ingredients of interdisciplinary pain
management. One of the most important components is a regularly scheduled staff meeting
consisting of all team members. The information presented affords staff members essential data
allowing each team member to work more effectively with the patient. Moreover, patient care
conferences, with all treatment team members present, facilitate the most valid perception of the
patient and help unite the team with regard to the direction and progress of treatment. The result of
this free flow of information and team interaction is an alignment regarding treatment goals, and it
helps ensure that a consistent message and clear expectations are presented to the patient, another
crucial factor in properly treating pain patients.
Finally, the unified approach limits the opportunity of staff splitting. Table 16.2 summarizes
the essential factors that can significantly promote success of the interdisciplinary pain manage-
ment program.
Once essential team members have been selected, the team leader must set treatment goals.
Determining successful treatment for chronic pain patients can be a difficult task. According to
Katz (1998), the goal of pain management “often cannot be complete relief of all pain” (p. 2S).
Keeping this in mind, ascertainable treatment goals should focus on a functional rehabilitative
model versus an investigative curative approach. As such, the goals are usually specific, definable,
operationalizable, and realistic. This includes identifying and managing any unresolved medical
problems, reducing and improving symptoms, eliminating any unnecessary medications, and
curtailing inappropriate use of the health-care system. Another important aim is increasing patient
independence and restoring physical, social, and occupational functioning in the patient’s life.
In order to achieve these goals, the treatment team must form a strong alliance with patients and
instill in them the need to self-manage their pain and take responsibility for their well-being
(Bendix et al., 1996). Turk and Gatchel (1999) note that implicit in interdisciplinary treatment is a
transfer of responsibility from the health-care provider to the patient.
TABLE 16.2 Essential Elements of Interdisciplinary Pain Management Programs

Schedule regular meetings to (1) ensure proper communication between team clinicians and (2) strengthen
established mutual goals for each patient.
Communication value and respect for each treatment team member’s skills and mutual reinforcement with
regard to each member’s role and efforts with the patient.
Systematic monitoring of the patient’s progress and outcome is essential to optimize quality assurance.
All staff members must understand and accept the treatment philosophy and interventions of the treatment
team.
Tertiary prevention has been described in the above paragraphs. However, primary prevention
of chronic pain is an intense area of study at this time. Unfortunately, few prevention measures have
undergone rigorous empirical evaluation and those that have do not currently appear promising
(Linton, 1999). Most attempts at interventions have focused on instructing workers at risk in
physically demanding jobs on safer ways to perform their duties, such as lifting, or making the job
safer for the worker (Frank et al., 1996). Educational measures, such as instructing the patient how
to properly lift, appear mediocre at best. Exercise appears to offer some benefit as an early intervention
(Linton, Bradley, Jensen, Spangfort, & Sundell, 1989).
Summary and Conclusion

Our conceptualization of chronic pain has changed with the adoption of the biopsychosocial
approach. It recognizes the various forces that impact a person’s perception of his or her pain and
disability. It guides us in both our approach to assessment as well as to treatment. When patients
undergo care that focuses on these important aspects, their chances for success are greater than if
only one aspect is examined.
It should also be noted that several important organizations in the United States have recently
developed new standards for the evaluation of pain. The Joint Commission on Accreditation of
Health Care Organizations requires that physicians now consider pain as a fifth vital sign (added to
the other vital signs of pulse, blood pressure, core temperature, and respiration). It requires that
pain severity be documented using a pain scale, in addition to the patient’s own words to describe
his or her pain (such as location, duration, etc.). This information, along with the present pain
management regimen and effectiveness, the patient’s pain goal, and the physical examination,
should be documented on initial assessment. These new standards are now being scored for com-
pliance in accredited health-care organizations (JCAHO, 1999). Moreover, the nonprofit American
Pain Foundation has created a “Pain Care Bill of Rights” informing patients of this requirement.
Such initiatives have created a new mandate for primary care physicians to successfully assess and
manage all types of pain, malignant as well as nonmalignant.
Acknowledgment
The writing of this article was supported in part by grants 2 KO2 MH01107, RO1 DE10713 and
RO1 MH 46452, awarded to the second author, from the National Institutes of Health.
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Chapter 17
Psychosocial Interventions With Type
1 and 2 Diabetes Patients
GLENN M. CALLAGHAN, JENNIFER A. GREGG, ENRIQUE ORTEGA, AND

KRISTOFFER S. BERLIN
Diabetes mellitus is a chronic disease that is very costly, both in terms of medical care expenditures
and disability, for the nearly 17 million Americans who live with it. In the past decade, researchers
have demonstrated that intensive pharmacological and self-management treatment can prevent
or postpone complications of diabetes, such as blindness, amputations, renal failure, and death.
However, given the high level of self-management required, many patients do not adhere to recom-
mendations. In this chapter, we describe a biopsychosocial approach to diabetes, which utilizes key
psychosocial factors and diabetes management, for the treatment of diabetes in a primary health-
care setting.
Diabetes as a Biopsychosocial Phenomenon

Diabetes mellitus is a chronic, costly, and potentially fatal disease that requires a large amount of
self-management by patients. The extensive behavior and lifestyle change required places a large
amount of treatment responsibility on the patient, rather than the clinician, and makes successful
adherence to medical recommendations for diabetes very difficult for many patients. Thus, the
psychosocial and behavioral aspects of treatment for this chronic condition play an important role
in successful treatment.
Definition
Diabetes mellitus is a metabolic disorder affecting the body’s capacity to produce or respond to
insulin, a hormone that allows blood glucose to be used for energy. Diabetes falls into two main
categories, types 1 and 2. Type 1 is characterized by problems with the body’s production of insulin
and typically has an onset during childhood or adolescence. Type 2, the more common form of the
disease, is characterized by a failure to produce sufficient levels of insulin or to sufficiently utilize
the insulin that is produced by the body. Historically, type 2 diabetes has had an onset usually
occurring after age 45, though it is becoming more common to see onset of type 2 diabetes at an
earlier age.
329
Type 1 diabetes requires continual maintenance of proper insulin levels. To date there are no
strategies for the prevention of type 1 diabetes. Type 2 diabetes is associated with obesity and a
family history of the disease (CDC, 2002). Type 2 diabetes has potential prevention strategies to
avoid its onset, aimed at lifestyle choices (such as diet and exercise) associated with the disease.
Physical inactivity as well as race or ethnicity (e.g., African American, Hispanic, American Indian,
some Asian American and Pacific Island groups) also contribute as risk factors for the disease. Type
2 diabetes accounts for 90–95% of all cases of diabetes (CDC, 2002). The prevalence of both types
of diabetes comprises an estimated 17 million people in the United States, or approximately 6.2% of
the population. Nearly 450,000 deaths are attributed to diabetes per year, and diabetes remains the
sixth-leading cause of death in the United States (CDC, 2002).
Heart disease is the leading cause of death among individuals with diabetes, with an incidence
two to four times greater than that of the nondiabetic population. In addition to death, physical
complications of diabetes include cardiopulmonary diseases, stroke, blindness, kidney disease,
nervous system diseases including diabetic neuropathies, retinopathy, lower extremity amputations,
dental disease, and pregnancy complications (CDC, 2002). Sixty to sixty-five percent of individuals
with diabetes have chronic hypertension, contributing to the higher incidence of stroke with diabetes
patients (e.g., Simonson, 1988).
Diabetes Self-Management
More than 10 years ago, the Diabetes Control and Complications Trial Research Group (DCCT,
1993) drastically changed the way diabetes is treated by reporting that in this controlled, prospec-
tive trial of more than 1,400 individuals with type 1 diabetes, intensive management of blood
glucose levels led to tighter glucose control, which led to reduced diabetes-related complications.
Five years later, similar results were demonstrated with more than 5,000 individuals with type 2
diabetes in the United Kingdom Prospective Diabetes Study (UKPDS, 1998).
Given these and other results, the contemporary medical management of diabetes attempts to
keep blood glucose levels near nondiabetic levels. This treatment varies depending on the type of
diabetes and can include a carefully calculated diet, planned physical activity, blood glucose testing
multiple times per day, use of medications to improve natural insulin production and response, and
the administration of exogenous insulin (ADA, 2000). The medical interventions for type 1 diabetes
include instructions about dietary restrictions and information about physical exercise and insulin
administration in the form of two or more injections per day or the use of an insulin pump. Medical
interventions for type 2 diabetes can include instruction about diet and increased exercise, the use
of oral prescription medication for the regulation of glucose levels (e.g., metformin) and increasing
effective responses to insulin (e.g., pioglitazone), as well as daily insulin injections for some patients
(ADA, 2000). Self-management, or the patient’s control and regulation of the disorder, is integral to
the treatment of diabetes (ADA, 1998). Recent American Diabetes Association (2000) treatment
recommendations and guidelines suggest that treatment should be tailored to the individual and
should address medical, psychosocial, and lifestyle issues.
Although the medical management of diabetes is important, the need for psychoeducation
interventions is apparent, given the high level of self-management required in diabetes. Despite the
repeated recommendations by the American Diabetes Association (2000) and the clear need for a
more comprehensive, integrated-care model, Clement (1995) reports that fewer than 50% of
individuals with diabetes ever receive more than limited self-management education. Of individuals
with type 2 diabetes who do not use insulin, 76% report never having attended any educational
program for their diabetes (Coonrod, Betschart, & Harris, 1994).
Psychosocial Interventions With Type 1 and 2 Diabetes Patients • 331
Despite the importance of diabetes education, however, education alone may not be sufficient to
bring about desired behavior change. In a review of diabetes self-management interventions, Clement
(1995) reported that none of the seven studies using only didactic education methods demon-
strated improvement in glucose control. In contrast, he reported that interventions that utilized
behavior change strategies, in addition to education, produced improvements.
Another issue related to diabetes self-management education is the setting in which treatment is
delivered. Janes (1995) reported that individuals with diabetes are more likely to receive medical
care for their diabetes in a primary care setting, while another study found that individuals with
diabetes receive better care from diabetes-focused treatments than general medical clinics
(Ho, Marger, Beart, Yip, & Shekelle, 1997). Regardless of where treatment is delivered, a multidisci-
plinary health-care team is continually advocated in the area of diabetes intervention (e.g., Boland,
Ahern, & Grey, 1998; Funnell, 1996; Harris & Lustman, 1998). This multidisciplinary team
provides education about and treatment of psychological problems, as they are related to diabetes,
together with the necessary medical treatment. This coordinated-care approach results in a better
standard of living for the patient and has been demonstrated to be more cost-effective than conven-
tional (i.e., medical only) treatments (Jacobson, 1996; Neff, 1999; Tucker, 1999).
Psychological Complications
Psychological complications contribute significantly to the health of the individual with diabetes.
The initial distress of being diagnosed with such a disease is only the beginning of a difficult
psychological path for these patients. According to a recent study, as many as 25% of individuals
with diabetes experience recurring emotional problems such as depression, anxiety, and eating
disorders (Harris & Lustman, 1998). Psychological problems suffered by diabetes patients have
been related to the risk of elevated glucose and difficulties in controlling these levels (Jacobson,
1996).
Depression has been found to be much more prevalent among patients with diabetes than those
without diabetes (18.5% versus 11.4%, respectively; Neff, 1999). Approximately 15–25% of adults
with either type 1 or type 2 diabetes have major depression (Tucker, 1999). This is more than twice
the level of depression found in the general population. Depression has also been associated with an
increased risk for diabetic complications, poor control of glycemic levels, and a reduced quality of
life, although the mechanisms of this relationship are not yet fully understood (Lustman et al.,
2000; Tucker, 1999).
Economic Cost
Complications created by psychological problems and nonadherence lead to a very high economic
burden for the individual patient and managed-care systems (Selby, Ray, Zhang, & Colby, 1997).
Of the $44.1 billion estimated direct medical expenditures for diabetes in 1997, $11.8 billion was
attributed to the treatment of chronic complications (ADA, 1998). Indirect costs of diabetes
(including work absenteeism, disability, and premature death) have more recently been estimated
at $132 billion yearly (ADA, 2000). Although the literature has not yet investigated a direct relation-
ship between psychological problems and the direct cost of chronic diabetes complications, the two
may have an important relationship. For example, depression is associated with poor glycemic
control, which increases the risk of complications, and, thus, the costs associated with treating
diabetes (Lustman et al., 2000). Total annual health-care costs are significantly higher for individu-
als with diabetes and depression ($6,800 average per person) than for individuals with diabetes
without depression ($4,300 average per person; Neff, 1999). This relationship between depression,
adherence, and its associated costs indicates the necessity of addressing psychological disorders
when treating diabetes from a coordinated-care perspective. Further, these findings support the
importance of a behavioral health-care provider’s being involved in the treatment of the individual
with diabetes. The treatment of depression for individuals with diabetes would likely improve their
glycemic control indirectly by facilitating better adherence to the treatment program.
One efficient way to address both psychological and self-management issues for individuals with
diabetes is through the delivery of diabetes self-management education in a psychoeducational
group. Efficiency is increased because at one group session a behavioral health-care provider can
see as many as 10 to 15 patients, and in this area group education has been shown to be as effective
as individual education (Norris, Engelgau, & Narayah, 2001). Given the potential benefits in
efficiency and social support of delivering care in a group format, the recommendations in this
chapter for psychoeducational interventions for patients with diabetes are made with group treat-
ment in mind. However, if patients require additional psychological services or have difficulty
participating in a group format, individual sessions may be used as well.
Diabetes serves as a model disease for the integration of psychosocial or psychoeducational
treatments into standard medical management. Psychoeducational treatment components directly
address the prevention and treatment of both medical and psychological complications and
promote the adherence necessary for the successful management of diabetes.
The Integrated Care Treatment Model of Diabetes
Targeted Areas of Intervention

Recommendations based on research for psychoeducational treatments for diabetes can be catego-
rized into five main areas: (1) educational information, (2) coping skills and stress management,
(3) social support, (4) diet, and (5) exercise. We suggest a comprehensive psychoeducational
approach to the treatment of diabetes that combines elements of each of these areas. This compre-
hensive treatment better serves patients with diabetes than treatments focusing on only one or two
areas (see, e.g., Howorka et al., 2000). Although type 1 and type 2 diabetes remain different in
important ways with respect to onset and medical management, the principles of psychosocial
interventions apply to both, and an intervention can be conducted that serves both types of patients
simultaneously. For this reason, this discussion will group both types of diabetes patients together.
Specific considerations for each type of diabetes are highlighted for behavioral interventions for
diet and exercise, but the other components address psychosocial issues common to both types.
Each of the five main areas listed above have been investigated as separate interventions and have
gained empirical support as being necessary but not sufficient interventions for the successful
management of the disease. Only recently have researchers advocated the integration of psychological
interventions with more traditional areas of focus such as education, diet, and exercise (e.g., Harris
& Lustman, 1998; Howorka et al., 2000). To date, there are no standard, empirically supported
treatments that have integrated all five areas of intervention.
The Take Charge! Treatment Protocol

Three of the authors of this chapter (GC, EO, & KB) have created a new treatment manual based
on recommendations from the empirical literature that combines each of these five areas into one
5-week protocol called Take Charge! (Callaghan & Ortega, 2001; Callaghan, Ortega, Uribe, & Berlin,
2001). All five of these areas were integrated as an attempt to help patients successfully manage the
disease in combination with taking their prescribed medications. In this treatment, each of the
five areas is addressed as its own module in a group treatment. There is a strong emphasis on
gaining social support for successful management of the disease throughout the treatment. To this
end, patients are encouraged to bring one “support person” to each session. This person may be a
partner, family member, or friend. Ideally, it is someone who is invested in the patient’s health and
well-being.
The group is structured so that it meets once per week, and meetings last for 90 minutes. Doctoral-
level psychologists and psychology trainees conduct the groups. Each module presents information
didactically and requires each patient to complete specific in-and-out-of-session activities. Because
the treatment is conducted in a group format, as many as 10 patients can be seen at a time. The pro-
tocol is designed so that only one health-care professional is needed to conduct the group.
This Take Charge! treatment protocol was recently evaluated in a small treatment outcome study.
Although the results of the study are preliminary and based on a small, uncontrolled sample, they
suggest that this treatment may be effective in increasing adherence to medical treatment, decreasing
blood glucose levels (as measured by HbA1C), increasing psychological functioning, and increasing
quality of life in a community primary health-care clinic (Dhanjal, Callaghan, Rosito, Wang, &
Waddel, 2002). These changes were related to social support and psychological health, dietary
changes, amount of exercise, as well as increases in the frequency of glucose self-monitoring. At a 3-
month follow-up, several patients reported lasting decreases in HbA1C blood glucose values, indicating
sustained behavioral improvements relating to diabetic management.
The following presents a discussion of each of the five areas of intervention in the contemporary
management of diabetes. The modules are numbered in sequence to correspond to the order in
which they appear in our treatment protocol. We have ordered them this way because it makes con-
ceptual sense to build upon the information related to education about the disease; however, there
is no evidence to suggest that they cannot be conducted in a different order than provided here.
Education. Education about diabetes has evolved considerably in the past 20 years. The American
Diabetes Association (ADA) recognizes diabetes education programs that train individuals in
programs that meet ADA standards. Education areas typically focus on information about how
diabetes affects the body, nutrition, and self-monitoring of glucose levels. Meta-analyses of research
on education interventions repeatedly show that education is important in the management of
diabetes (Brown, 1988, 1992; Padgett, Mumford, Hynes, & Carter, 1988), but, as noted above, it
may not be sufficient for effective self-management interventions (Clement, 1995).
Areas of education that are important to address in psychoeducational interventions include the
following:
• Information about what diabetes is as a disease.

• An understanding of the role of insulin in the body and how insulin relates to diabetes.
• Information about causes for both types 1 and 2 diabetes.
• Understanding the difference between type 1 and type 2 diabetes and knowing which type
a patient has.
• Information on the importance of maintaining healthy glucose levels, what those levels
are, and how to conduct the self-monitoring tests.
• Understanding hypo- and hyperglycemic events.
• Information and instruction about the importance of foot and eye care including self-
monitoring for problems.
Education about diabetes, particularly more comprehensive programs that include the areas
emphasized above, remains an integral part of any psychologically based intervention because it
may help to promote patient compliance through an understanding of diabetes and the disease
process. For example, a basic understanding of how changes in blood sugar levels affect the patient’s
feeling of having energy may provide better prompts for maintaining appropriate glucose levels.
Similarly, patients who understand the relationship between circulation problems and nerve
damage (peripheral neuropathy) may be motivated to better take care of their feet.
Although these interventions may be important, the disconnection between diabetes and educa-
tion and behavior change suggests that there may be additional barriers that prevent patients from
acting on this education material. These barriers can be addressed in the following components,
focusing on coping skills and stress management strategies.
Coping Skills and Stress Management. As described earlier, depressive disorders in individuals
with diabetes have been linked to poor glycemic control (Lustman et al., 2000) and a corresponding
increased risk of complications (Anderson, Lustman, Clouse, De Groot, & Freedland, 2001). The
fact that the prevalence of depression among individuals with diabetes is nearly twice as high as that
of the general population in the United States indicates the necessity to include the screening and
appropriate treatment for depression and other psychological problems among diabetes patients.
Stress, difficulties coping with diabetes, and difficulties making necessary behavioral changes
have also been associated with poor glycemic control and increased risk of complications (Kramer,
Ledolter, Manos, & Bayless, 2000). Research investigating the inclusion of coping skills training in
the treatment of diabetes indicates that these skills help patients lower glucose levels, assist with
their medical management of the disease, and decrease the negative impact of diabetes on their
quality of life (Grey, Boland, Davidson, Li, & Tamborlane, 2000). The coping-skills training to be
implemented by the behavioral health-care provider includes social problem solving, cognitive and
behavior modification, and conflict resolution.
Suggestions for psychoeducational treatment components in this area include:
• Screening for depression and appropriate treatment if mood disorder is present.

• Coping-skills training using cognitive behavioral strategies.
• Focusing on such topics as family adjustment, stress management, eating disorders.
• Focusing on parenting and marital issues as they are related to diabetes and an adjustment
to a new lifestyle.
More general and long-term suggestions for treatment approaches in this area include the use of
support group meetings that facilitate sharing of information, treatment plans, effective coping
skills, anecdotal experiences, and resources by the patients. These groups can be conducted in tandem
with the psychoeducational intervention, or they could be offered as less structured, after-care
support groups. The overarching suggestion for this aspect of diabetes treatment is that the mental
health professional be competent to facilitate behavioral changes that assist patients’ adherence to
treatment, develop patients’ coping and adjustment to new lifestyles, as well as address eating disor-
ders if present. This may entail using a psychotherapist such as a licensed marriage family therapist
or licensed clinical social worker who has had experience delivering psychosocial or psychological
interventions.
In our Take Charge! treatment protocol we propose specific tasks for developing effective coping
skills and stress management strategies. These include (1) teaching patients how to decrease the
general levels of stress in their lives; (2) the use of relaxation strategies and meditation, the use
of exercise; (3) taking a time-out from stressful situations; and (4) using social supports to help
deal with stress. We suggest that it is also useful to address the specific stress that diabetes can add to
a patient’s life. We advocate helping patients to adjust to the changes in their lives slowly and in
small steps in areas where this is possible. Helping patients prioritize which areas need to be
addressed and changed first (e.g., with diet or exercise due to obesity or pulmonary problems) is
also a key task.
One of the difficulties patients encounter with managing their diabetes occurs as a result of
avoiding the thoughts or feelings associated with being diagnosed and living with a chronic disease.
Acceptance of the fact that patients have the disease, and that they wish they did not, may also be an
important coping strategy to teach. We further discuss the role of acceptance later in the chapter.
Social Support. Social support has been recognized as an important element in the treatment and
management of diabetes. Family and friends play an important role in this process through their
assistance with selecting and preparing meals, providing care, and helping the patient cope with
stress. Social support and encouragement greatly influence the patient’s coping, management, and
attitude toward their condition (Wallhagen, 1999).
Considerations for treatment interventions regarding social support include
• Orienting patients to the importance of social support and involving friends and family to
assist them with the management of their disease.
• Helping patients understand that they are not alone in having diabetes, that they do not
have to struggle in isolation.
• Informing patients of other social support outlets.
• Providing group sessions with other individuals with diabetes to promote the develop-
ment of support networks and learning new coping strategies from others.
• Providing an “awareness” session with the patient’s friends and family about the import-
ance that they have in the treatment and management of their loved one’s condition.
• Assisting the patient and their friends or family with the adjustment process of having and
managing diabetes.
Providing the above components in a social support intervention can be very beneficial to the
individual with diabetes. As discussed earlier, we recommend directly involving at least one primary
support member for a patient. This person can come to each of the psychoeducational group
sessions to better understand how to help the patient manage his or her disease. Both the patient
and family member need to understand that diabetes is a lifelong management issue. Together, the
patient with diabetes and his or her family member or friend can work as a team. With effective
management the patient can live a long, happy, and healthy life.
We also propose that it is useful to teach patients some basic social skill strategies including
using active listening strategies and assertion skills. One important area in which to implement
these socially based strategies is with the patients’ physician, and the behavioral health-care specialist
can address patients’ concerns about how to talk with their doctor and instruct them in making
clear, specific requests about their medical needs. In the service of helping the patient become more
effective and to manage costs associated with unnecessary health-care visits, it is also useful to teach
the patient to discriminate when a diabetic emergency occurs, when to contact the physician, and
when to rely on other sources of support.
Diet. Nutrition, diet, and obesity continue to be among the most problematic areas for interven-
tion, for both patients with diabetes and for health-care service providers. Despite the consistent
need for a balanced diet and the empirical documentation of the role that nutrition and obesity
play in chronic health problems, particularly with diabetes, there are no consistent research findings
to suggest the best intervention with respect to dietary change strategies for individuals with
diabetes. Historically, dietary recommendations for both type 1 and 2 diabetes have focused on
(1) providing an extensive list of prohibited foods to prevent glycemic events and increased levels of
hemoglobin A1c values (ADA, 1994), and (2) giving explicit recommendations to individuals with
type 2 diabetes to lose weight. These two traditional approaches have met with limited success.
More recently, there has been much attention paid to low carbohydrate diets for individuals
with diabetes, but, given the numerous health problems experienced by these patients, such recom-
mendations have not been applied broadly by most physicians. Ultimately, dietary change is
complicated, and in diabetes there is no specific diet or meal plan that will work for everybody, so
encouraging individuals with diabetes to lose weight through a plan that takes into account their
specific circumstances is often most effective.
Although there is no magic diet, there are some general suggestions and guidelines for address-
ing behavioral change in diet and nutrition (ADA, 1994). These suggestions state that health service
providers consider important contextual variables such as race or ethnicity and previous dietary
habits when planning any individualized diet plan. According to the American Diabetes Associa-
tion, for medical nutrition therapy to be effective, an individualized meal plan should be developed
that considers the individual’s normal eating habits, being sensitive to cultural and ethnic food
values, as well as what the individual is willing and not willing to do (ADA, 2000). Meal plans
should be developed keeping in mind specific goals, such as improved metabolic control, maintaining
healthy body weight, and preventing short- and long-term complications. Because many dietary
factors may be complex to the untrained person, it is recommended that a dietitian or nutritionist
knowledgeable about diabetes be involved in meal planning as well as any type of nutrition assessment.
General suggestions for a diabetes diet-intervention protocol include the following considerations:
• A nutrition assessment should be conducted to determine the patient’s individualized

meal plan as well as treatment goals.
• Group meetings can be held in which specific information is presented on the relationship
of nutrients to blood glucose levels, serum lipid levels, as well as the optimum levels of
calories, carbohydrates, fat, protein, and cholesterol that meals and diets should include.
• Instruction in counting carbohydrates and grams of fat should be provided to help the
patient keep track of nutritional intake.
• A dietician or other health-care provider should give information and assistance on the
use of insulin, insulin regimens, as well as insulin and food adjustment procedures.
• Information should be provided in group meetings on short- and long-term complication
risks and how certain foods and diets prevent these.
• A periodic assessment of goals and adherence to dietary plans should occur throughout
treatment.
Specific recommendations for dietary changes for better health must to be tailored to the indi-
vidual. However, some recommendations apply to many individuals with diabetes, including these:
• Recommend that the patient try choosing food products low in sodium, sugar, and fat
when grocery shopping.
• Advise the patient to prepare meals that are baked, broiled, or grilled and not fried.
• Recommend that the patient try flavoring foods with herbs or lemon juices instead of
using salt and to try to minimize or reduce foods with creamy sauces, butter, and rich desserts.
• Suggest that patients eat lean meats and plenty of vegetables.
• Suggest that patients consult with their doctor about how much fruit is acceptable to eat,
given the risk of glycemic events associated with natural sugars.
In an ideal treatment setting, patients with diabetes would be referred to a nutritionist who
would help the patient develop a tailored diet plan based on his or her precise needs. This is often
not the case, but the role of the nutritionist should not be overlooked in any setting. If the patient
has been diagnosed as having nutrition-related health deficiencies, evidences or reports of food
allergies, specific food requirements or restrictions based on an ideology or belief system, or other
needs that go beyond the general recommendations made in a psychoeducational intervention, a
nutritionist should be consulted.
Another area of focus with dietary considerations concerns the use of tobacco and alcohol. It is
in most patients’ best interest to reduce or eliminate smoking. For individuals with diabetes, circu-
latory and cardiovascular problems are especially prominent, and smoking tobacco is known to be
related to heart and lung disease. Given the prominence of heart disease with this population,
specific counseling on the effects of smoking is highly recommended.
Alcohol consumption is a difficult issue for individuals with diabetes. It may be necessary
to treat a co-morbid alcohol dependence problem for some patients. However, for those patients
who drink in moderation, it is important to assess the quantity of alcohol consumed and provide
some basic education on the relationship between alcohol and diabetes. Metabolizing alcohol can
be difficult for some individuals with diabetes. The symptoms of hypoglycemia and intoxication are
similar (e.g., thick-tongued speech, shaking, staggering walk, mental confusion, etc.), and people
may confuse these symptoms and ignore or delay treatment of diabetic insulin reactions.
Some individuals with diabetes can drink alcohol in moderation with few adverse health effects,
but only if their diabetes is in good control. It is recommended that individuals with diabetes not
drink more than one serving a day, where one serving is 4 ounces of wine, 12 ounces of beer, or
1.5 ounces of hard liquor. Additionally, individuals with diabetes should drink only when eating a
meal and they should be advised to avoid sweet liqueurs or mixes because of their high sugar content.
Exercise. Nutritional recommendations are most effective as dietary and weight loss strategies
when coupled with an exercise program. As with planning a diet, diabetes patients should consult
with their physicians to determine the best exercise regimen for them. Exercise helps control blood
sugar levels, reduces the risk of complications such as nerve and eye damage, and protects against
heart disease (Stanten, 2000). However, many individuals with diabetes receive minimal informa-
tion about exercising, perhaps owing to complexities involved in maintaining normal blood sugar
levels during such activities (Colberg, 2000).
Type 1 diabetes patients need a basic education of physiology to understand how varying blood
sugar levels produce negative effects such as an increased risk of cardiovascular, foot, and hypogly-
cemic problems. For this reason, individuals trained in exercise physiology with knowledge in the
area of diabetes are recommended to assist the patient develop an exercise program. The health-
care provider should understand and have the necessary training to analyze the risks and benefits of
exercise to the patient (ADA, 2000).
For individuals with type 1 diabetes, research indicates that exercise does not help improve
diabetes management with respect to glycemic control. However, exercise helps boost cardiovascular
fitness. For individuals with type 2 diabetes, exercise programs, when combined with appropriate
medical treatment, increase glycemic control and reduce risk factors for heart and circulatory prob-
lems (ADA, 1996).
General recommendations for planning exercise-based interventions for individuals with
diabetes include the following:
• A detailed medical evaluation, a thorough screening for cardiovascular conditions, and an

individualized risk evaluation should be conducted for each patient. This evaluation
should include specific assessments for hypertension, neuropathy, retinopathy, and

ischemic heart disease. An exercise EEG may be indicated for patients over 35 (ADA,
1996).
• Education should be provided about basic physiology as related to body and exercise
(energy use, bodily responses, body fuels).
• Patients should continue to self-monitor glycemic levels and immediately adjust their
exercise regimen accordingly.
• Patients should have a personalized training regime based on individualized evaluations.
Specific recommendations for an exercise plan, as with the dietary intervention, should be
tailored to the individual and be done in coordination with the patient’s physician. Some additional
recommendations also include the following:
• The patient should always wear something that identifies him- or herself as a person with
diabetes.
• The patient should have a card with his or her name and the phone number of contact
persons in case of an emergency. This is especially important when exercising outside.
• The patient should set aside a special time during the day, and days of the week, to
exercise.
• It is important to remind the patient to eat at least 1 to 2 hours before exercising and to be
aware of how exercise affects the body.
• If the patient feels weak or faint, he or she should immediately discontinue exercising and
make sure to tell the doctor.
• Patients should always carry a fast-acting sugar such as glucose tablets, honey, or a hard
candy in the event a hypoglycemic event occurs.
• Patients should continue to monitor their blood-sugar levels frequently to notice any
changes. If blood-sugar levels become too high or low, the patient should discontinue any
activity immediately so that he or she can normalize glucose levels with certain foods with
fast-acting sugars or extra insulin as appropriate.
Issues Associated With Successful Treatment Delivery

The following sections address some of the specific issues associated with delivering a psychoeduca-
tional treatment protocol effectively in a health-care setting. These issues include the motivation of
patients with respect to treatment adherence, problems associated with emotional avoidance, and
the type of practitioner needed to deliver psychoeducational treatments.
Addressing Motivation and Patient Adherence

Patient adherence to treatment recommendations can be difficult to achieve. The research literature
on promoting adherence is scant and has centered largely on educating patients about the disease.
Recently, psychological behavior change models, such as Prochaska and DiClemente’s (1982, 1986)
stages of change model, have been applied theoretically to diabetes (e.g., Ruggiero & Prochaska,
1993). Increased attention is being paid to the utilization of psychological principles to tackle moti-
vation with this population.
In our approach, we have attempted to address this by having patients explicitly state their goals
and values for healthy living. We then tailor the intervention to each patient in the group based on
his or her own goals. This assumes, however, that patients hold the goals of healthy living. It is
unclear how to motivate or increase a desire to live a healthy life if it is not held as a value.
Alternatively, another factor thought to be a motivator in diabetes is information on the costs of

not taking care of one’s diabetes—specifically information about complications such as blindness,
amputation, and death. It remains unclear, however, whether this knowledge will motivate behavior
change (e.g., Clement, 1995).
Avoidance, Acceptance, and Diabetes

Acceptance as a strategy for coping with a chronic disease has recently emerged as an area of poten-
tial focus for interventions. Acceptance theorists suggest that it is the avoidance of psychological
discomfort, such as thoughts and feelings about having to deal with diabetes for the rest of one’s
life, that may contribute to nonadherence to treatment recommendations (e.g., Hayes, Strosahl, &
Wilson, 1999). For example, a patient with diabetes may be distressed about the possibility of blind-
ness, amputation, or even death, and may therefore avoid thoughts about having diabetes in order
to not have to feel this distress. This avoidance may then lead to a decrease in diabetes self-
management behaviors.
Acceptance theorists advocate treatments that develop skills that reduce avoidance strategies
and increase patients’ abilities to experience aversive emotions related to their disease, such as
acceptance and commitment therapy. This area is new to disease management and is only just now
being investigated in diabetes; we include it here because it may be an important area of assessment
and intervention. Recently, a measure has been developed (Acceptance/Avoidance Diabetes Ques-
tionnaire, AADQ; Callaghan & Gregg, 2001) that assesses the extent to which individuals with dia-
betes actively avoid their thoughts and feelings associated with the disease. Each patient’s response
to the AADQ helps identify areas of avoidance that may inhibit the patient’s ability to fully engage
self-management behaviors. For example, if a patient indicates that he or she is working very hard
not think about his or her diabetes and will avoid the stimuli or materials associated with diabetes,
that patient may be less likely to test his or her blood glucose. In this case, we would focus on help-
ing the patient learn to experience those feelings of fear of the disease, to accept those as natural
feelings, and to engage in the behaviors necessary to prevent an early death and have a healthier life.
Health-Care Providers for Diabetes Interventions

In an integrated health-care model, the medical management of diabetes remains under the direc-
tion of the physician. However, any behavioral health-care provider with proper training (except of
course, where a specialist is required) can provide all the components of the psychoeducational
interventions described above. In addition, certified health-care specialists such as physicians’
assistants, nurse practitioners, certified diabetes educators, or registered nurses can provide these
interventions in coordination with the primary care physician. Regardless of who conducts
the intervention, any health-care provider working with patients with diabetes must know the
limits of their knowledge. Due to some of the specified knowledge required for physiology and
nutritional aspects of a comprehensive approach to diabetic care, health-care providers should
continue to consult with a physician, and when possible, involve specialists such as dieticians,
nutritionists, and others.
Assessment of Variables Important to Diabetes

There are many domains to assess with diabetes interventions. These fall into five main categories:
knowledge, medical, diet, psychosocial, and economic costs. There are numerous devices available
in each of these domains, and they can provide important information about the effectiveness of
the psychoeducational intervention and provide an assessment of accountability to the patient and
service provider. The specific devices described below can be given pre- and posttreatment to help
determine the effectiveness of the intervention. These devices are applicable to all individuals with
diabetes, though they require the patient to be able to read. Literacy and vision impairments
(e.g., retinopathy) should be determined before using these assessments.
A good general comprehensive assessment device is the Diabetes Care Profile (Fitzgerald et al.,
1996), which assesses multiple domains pertaining to diabetes including dietary strategies, amount
of education received, impact of diabetes on lifestyle, and level of psychological distress. Another
general assessment device is the Diabetes Self-Management Profile (Harris et al., 2000), which
assesses various components of the regimen including exercise, management of hypoglycemia, diet,
blood glucose testing, and insulin administrations and dose adjustment. However, a broadband
multimethod assessment approach is advocated with interventions for individuals with diabetes.
Improvements shown on one assessment device for one domain should correlate with improve-
ments shown in other domains, but this is not necessarily the case. It is important to determine the
nature of discrepancies in divergent or inconsistent data from assessments of the different domains.
Knowledge
Knowledge assessments such as the Diabetes Knowledge Scale (Hess & Davis, 1983) or Brief Diabetes
Knowledge Scale (Fitzgerald et al., 1998) attempt to determine what the patient knows about the
facts of the disease. This is a good assessment device to use to determine the effectiveness of an
educational intervention.
Medical
The primary variable assessed for diabetes is the effective maintenance of healthy glucose levels.
Typically a test called glycosylated hemoglobin or hemoglobin A1c (GHb or HbA 1c is used.
The HbA1c is a measure of average blood glucose for the preceding 3 months and is considered the
gold standard for indexing metabolic control (Goldstein, Little, Wiedmeyer, England, & McKenzie,
1986). Two variables that patients with diabetes report to physicians and health-care specialists are
the frequency of self-monitoring or testing of glucose levels and the value of the glucose level at
each test. Assessing glucose levels is useful to determine whether behavioral interventions lead to an
increased frequency of testing and impact glucose levels (e.g., Clement, 1995). Assessments of
blood pressure, medication compliance, foot and eye problems, and emergency room visits should
also be considered obligatory in this domain.
Diet
Variables related to dietary practices and changes can be readily assessed using measures of weight
loss, body mass indices, and self-monitored, weekly diet or meal record.
Psychosocial
Psychological or behavioral variables are numerous. The choice of an assessment device in this
domain should be tailored to the individual’s particular problems such as anxiety or mood prob-
lems. A general assessment of social support may be useful to track changes in utilization of support
networks (e.g., the Social Support Questionnaire by Sarason, Sarason, Shearin, and Pierce, 1987).
Because depression is so prominent among patients with diabetes, a good basic depression self-
report inventory is the Beck Depression Inventory (BDI or BDI-II; Beck, Steer, & Brown, 1996;
Beck, Steer, & Garbin, 1988; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). The BDI is an
instrument that rapidly assesses depression symptoms and provides an index for severity of distress.
Although the BDI is not a diagnostic tool, it is very helpful in determining the severity of a patient’s
affective disturbance and can be useful for determining the appropriateness of a referral to another
subspecialty clinic.
Assessing anxiety can be accomplished using the Beck Anxiety Inventory (Beck & Steer, 1997).
This brief self-report device has been reported to be both psychometrically sound and useful in
primary care settings for a variety of problems (e.g., Ferguson, 2000). General levels of stress can be
effectively assessed using the Symptom Checklist-90 (SCL-90-R; DeRogatis, 1977). The SCL-90-R
can yield a general index of psychological distress (Cyr, McKenna-Foley, & Peacock, 1985) that can
be used as in pre-to-posttreatment assessment.
Assessing treatment satisfaction can also be considered an important psychological variable,
particularly as it relates to the motivation of a patient to continue with the treatment. The Diabetes
Treatment Satisfaction Questionnaire (Bradley, 1994) is one example of many devices that address
patients’ satisfaction with the intervention.
Economic Costs
Assessment of economic costs can be conducted for both patients and service providers or health-
care agencies. For individuals with diabetes, assessments can include tracking the amount of money
patients spend on self-care supplies (e.g., testing strips, insulin, medication, syringes, and other
prescriptions), number and cost of doctor visits, emergency room visits, and specialty foods. Per
capita medical expenditures for individuals with diabetes have been estimated at $10,071 per year,
compared with $2,669 for people without diabetes (CDC, 1998). The economic costs of diabetes
come largely from treating complications due to poor management of the disease.
Economic Analysis of Treating Diabetes and Cost Offset Opportunities

The most obvious way to reduce costs associated with diabetes lies in prevention of chronic compli-
cations. The costs for managing diabetes are high; however, the costs associated with complications
such as amputations, emergency room visits, retinopathy, and nephropathy are staggering.
The single largest cost offset for a diabetes intervention would be to reduce the $11.8 billion spent
annually on treatment of complications.
A recent economic analysis of diabetes interventions yielded mixed empirical support for the
different types of treatment strategies (Klonoff & Schwartz, 2000). This report categorized inter-
ventions according to their economic impact, from clearly cost-saving to unclear impact, based on
the available data for the intervention. Cost-saving interventions include those focused on eye care
(prevention of retinopathy) and preconception care, nephropathy prevention in type 1 diabetes,
and improved glycemic control. These interventions produced clear savings medically and econom-
ically and ranged from cost savings between $1,000 to over $21,000 per patient per year depending
on the intervention (with higher savings for prevention of nephropathy).
Interventions that indicate equivocal findings with respect to demonstrated cost savings include
nephropathy prevention in type 2 diabetes and self-management training, case management, nutri-
tion therapy, self-monitoring of blood glucose, foot care instruction, blood pressure, smoking
cessation, exercise interventions, and weight loss (Klonoff & Schwartz, 2000). These equivocal
findings should not necessarily preclude the health-care provider from utilizing interventions
focused on these variables. For example, while the larger summary analysis by Klonoff and Schwartz
indicated questionable findings for the cost effectiveness of foot care interventions, Litzelman and
colleagues (1993) found a dramatic reduction in costs of health care using a basic intervention for
foot care. Other studies have shown similarly large cost savings, particularly in the reduction of foot
amputations, using similar approaches (Malone et al., 1989). In addition, reductions in direct costs
for amputations do not necessarily reflect the potentially massive savings in indirect costs associated
with the prevention of becoming physically disabled.
Enlisting and Maintaining Physician Collaboration

There is no empirical literature on enlisting and maintaining physician collaboration in the treatment
of diabetes. Clearly, a multidisciplinary team is not only advocated but required to accomplish the
multiple demands of a successful intervention. The following suggestions are based on a conceptu-
alization of how to effectively create a psychosocial intervention in the context of primary care.
First, the behavioral health-care specialist should determine that there is a need to provide addi-
tional care for patients with diabetes in a primary care setting. This can be done by explaining that
the path to having physicians provide the best care for their patients with diabetes is to address the
psychosocial variables in addition to the medical side of disease management. One way to approach
this is to ask the director of a health-care agency of a primary care physician what he or she needs to
supplement the care for their patients with diabetes.
Second, the behavioral health-care specialist can then describe the services that he or she can
provide to the patient that would accomplish the goals for the agency in treating the patient.
The health-care provider should develop clear and simple channels of communication with each
key team member in the primary care setting. This communication is essential for providing fol-
low-through and follow-up information to (a) inform the physician about progress and (b) deter-
mine the medical impact of the psychoeducational intervention on the patient. This information is
essential to reevaluate the intervention for opportunities to improve the treatment for the patient
and for the physician.
The overall key to involving physicians and other primary care management staff is to demon-
strate the effectiveness of a psychoeducational intervention in the collaborative management of
diabetes. This can be done by (1) conveying the effectiveness of the intervention as demonstrated in
the empirical literature, and (2) by gathering specific data for the patients treated by the behavioral
health-care specialist. Providing feedback about patients’ successes medically, psychologically, and
behaviorally is essential to demonstrating the important role that the behavioral health-care
specialist serves on this type of treatment team.
Prevention of Diabetes
Prevention of diabetes depends largely on perspective and the point of intervention. Secondary and
tertiary prevention efforts are geared toward the avoidance of complications as described above.
Primary prevention efforts are currently being intensely investigated (e.g., Julius, Schatz, & Silverstein,
1999), including examining the possibility of administering insulin to people at risk for type 1 dia-
betes to prevent or delay onset of the disease. Other prevention efforts for type 1 diabetes are geared
at screening and counseling at-risk individuals. Risk factors for the development of type 1 diabetes
includes first-degree relatives of patients with type 1 diabetes and ethnicity.
Prevention efforts for type 2 diabetes are aimed at preventing obesity and reduction in weight
for those who are obese. The risk of developing type 2 diabetes increases with age, obesity, and lack
of physical activity. Other risk factors for developing type 2 diabetes include those individuals with
a family history of diabetes and membership in certain racial or ethnic groups. The screen used to
detect the development of diabetes is the fasting plasma glucose test.
The role of the behavioral health-care specialist rests with preventing type 2 diabetes. Efforts
aimed at weight reduction, developing proper dietary habits, and increasing physical activity may
all work to help prevent the onset of the disease. The health-care specialist may also choose to
provide interventions aimed at the children of individuals with diabetes about the importance of
maintaining a good diet and engaging in exercise either through parenting instruction or directly
to children.
Summary
We have attempted in this chapter to outline the critical areas for a psychosocial intervention with
patients with type 1 or 2 diabetes. As a biopsychosocial phenomenon, diabetes affects patients in
numerous areas of their physical and psychological functioning. As such, health-care interventions
must address these multiple domains. A multidisciplinary intervention is warranted in treating
diabetes to develop better self-management skills. This intervention should address the areas of
education about the disease, the development of coping skills and stress management, use and facil-
itation of social support, development of better dietary habits, and engagement in an effective and
healthy exercise plan. With this multifaceted intervention, a systematic attempt is made to delay,
prevent, or ameliorate many of the medical and psychological complications associated with type
1 and type 2 diabetes so that patients with this disease can live healthier and happier lives.
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Suggested Reading/Websites for Diabetes Patients

Suggested Reading
Becker, B. (2001). The first year: Type 2 diabetes: An essential guide for the newly diagnosed. Marlowe.
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Websites
American Diabetes Association: www.ada.org
World Diabetes Foundation: http://www.worlddiabetesfoundation.org/
CDC Diabetes home page: http://www.cdc.gov/diabetes/
National Institute of Diabetes and Digestive and Kidney Disease: http://www.niddk.nih.gov/health/diabetes/diabetes.htm
RT9467_C018.fm Page 347 Friday, November 12, 2004 4:15 PM
Chapter 18
Increasing Medication Adherence in Chronic
Illnesses: Guidelines for Behavioral Health-Care
Clinicians Working in Primary Care Settings
ERIC R. LEVENSKY
Across patient populations and medical settings, inadequate adherence to prescribed medications
is a significant barrier to effective health-care delivery (Rogers & Bullman, 1995). Although
advancements in medicine have yielded effective medications for many illnesses, the beneficial
effects of these medications are often not realized because an estimated 50% of patients fail to
sufficiently follow the prescribed regimens (Sackett & Snow, 1979). This lack of adherence to medi-
cations not only reduces the impact of potentially effective treatments, but also can incur substan-
tial and unnecessary health and social costs (Cleemput, Kesteloot, & DeGeest, 2002). Adherence is a
particular concern for patients with chronic illnesses because patients on long-term medication reg-
imens generally have poorer adherence than those on shorter regimens, and medication adherence
tends to worsen over time (Cramer, Scheyer, & Mattson, 1990; Haynes, Taylor, & Sackett, 1979).
Behavioral health-care clinicians are increasingly being integrated into primary care settings in
an effort to better address psychosocial issues affecting patients’ physical and mental health (see
chapter 1 of this volume). The purpose of this chapter is to provide these clinicians with informa-
tion and strategies they can use to facilitate patients’ adherence to medication regimens. A large
body of research on adherence to medical treatment regimens has shown that inadequate adherence
to medications is often mediated by psychosocial factors and can be impacted by psychosocial
interventions (see below). Therefore, the task of increasing medication adherence is well suited to
the training and skills of behavioral health-care clinicians.
Specifically, this chapter will (a) discuss the nature and consequences of inadequate adherence
to prescribed medications, (b) briefly review the current state of the literature on factors related
to inadequate adherence, as well as strategies for increasing adherence, (c) discuss methods
of assessing patient adherence to medications, and (d) propose and describe guidelines for
a medication adherence intervention that can be integrated into primary care settings. Although
the focus of this chapter is on working with patients who have been prescribed long-term
medication regimens, much of this information has been found to apply to facilitating adherence
to short-term and nonpharmaceutical regimens such as dietary and exercise regimens as well
347
(see Dunbar-Jacob, Burke, & Puczynski, 1995; Meichenbaum & Turk, 1987; Shumaker, Schron,
Ockene, & McBee, 1998).
The Nature of Adherence and Nonadherence

Although there is much variability in the definition of the term adherence, it generally refers to the
extent to which patients follow the instructions they are given for prescribed treatments (Haynes,
McDonald, Garg, & Montague, 2002, p. 2). In recent years, the term adherence has begun to be
used in place of the more traditionally used term compliance. This shift in terminology has occurred
because many researchers and clinicians believe that compliance suggests passivity and obedience on
the part of patients, whereas adherence implies patient-provider collaboration and an active role of
patients in their treatment (Rogers & Bullman, 1995).
Nonadherence to medications can take a number of forms. These can include the following:
• Not filling the medication prescription or not initiating the treatment.
• Taking too many or too few pills at each dose.
• Taking too many or too few doses.
• Taking medications at the incorrect times (e.g., taking doses too close together or too
far apart).
• Not following special dosing instructions (e.g., food/beverage requirements).
• Terminating the treatment prematurely.
To the complexity of nonadherence, whether or not a patient is considered nonadherent to a spe-
cific medication can depend on how closely the regimen for that medication must be followed for
the treatment to be effective. For example, researchers have found that, in order for highly active
antiretroviral therapy (HAART) mediations to be effective in the treatment of HIV infection,
patients are required to take at least 95% of the doses, and the medication is also quite sensitive to
variations in the timing of doses (Andrews & Friedland, 2000; Barlett, 2002; Low-Beer, Yip,
O’Shaughnessy, Hogg, & Montaner, 2000; Paterson et al., 2002). Therefore, the definition of adher-
ence to HAART is often based on these criteria.
Health and Financial Consequences of Nonadherence

Poor adherence to medication treatments has been found to have a number of substantial health
and financial consequences (Rogers & Bullman, 1995). Health consequences can include (a) no
change in the illness or a worsening of the illness, (b) the development of collateral illnesses or
problems (e.g., opportunistic infections, resistance to the treatment), (c) the provider’s being
unable to evaluate the effectiveness of the treatment and erroneously increasing the medication or
discontinuing a potentially effective medication, and (d) death of the patient.
Financial consequences can include the cost of additional services and treatments needed to
address consequences of poor adherence (e.g., additional doctor visits, medications, and tests;
emergency room visits, hospitalizations, etc.), as well as decreases in the productivity of the patient.
Poor adherence to prescribed medications is estimated to cost over $100 billion each year in the
United States through increasing health-care utilization and decreasing patient productivity (Grahl,
1994; National Pharmaceutical Counsel, 1994).
Factors Related to Adherence and Nonadherence

Over the past several decades, a wide range of factors have been found to be associated with adherence
and nonadherence to mediations. However, most of these factors account for a relatively small
proportion of the variance in adherence and are not consistently related to adherence across studies
(see Fincham, 1995; Meichenbaum & Turk, 1987; Morris & Schulz, 1992; for reviews). Table 18.1
Increasing Medication Adherence in Chronic Illnesses • 349
TABLE 18.1 Factors Related to Poor Adherence to Medication in Chronic Illness Populations
Factors related to the patient:
• Lack of knowledge of regimen requirements (e.g., what to take, how much to take, when to take it,
etc.)
• Cognitive deficits (e.g., forgetfulness)
• Lack of adherence-related skills (e.g., problem-solving, organizational, memory aid skills, etc.)
• Lack of resources (e.g., financial, housing, transportation, time, etc.)
• Substance abuse (i.e., alcohol abuse and illicit drug use)
• Language deficits/poor literacy
• Stressful life events (e.g., death of loved one, loss of job, ending of important relationship)
• Emotional health problems (especially depression and anxiety disorders)
• Problematic beliefs about:
• Need for treatment/seriousness of the disease
• Efficacy of the treatment
• Importance of adherence
• Relative costs and benefits of adhering to the treatment
• Ability to adhere (i.e., self-efficacy)
• Inadequate social support (emotional, practical/instrumental support; help with medication
taking; encouragement of adherence, etc.)
• Apathy about health/future
• Problematic past experiences with adherence (e.g., ability to adhere, costs and benefits, etc.)
• Lack of intent to adhere
• Fear of stigma of taking medication/having illness
• Problematic responses to slips in adherence
• Taking medication is an unwelcome reminder of illness
Factors related to the medication regimen:

• High complexity/demands of the regimen (e.g., number of pills, frequency/timing of dosing, food/
water requirements, size of pills, storage requirements, etc.)
• Poor fit between regimen requirements and patient’s lifestyle/daily activities (e.g., eating and
sleeping patterns, work schedule, social life, other daily activities, etc.)
• Long duration of the treatment
• Frequent/severe side effects
• High cost of medication
• Poor portability of medication
• Inconvenient packaging of medication
Factors related to the patient-provider relationship:

• Poor communication between patient and provider
• Provider does not adequately assess problems with treatment/adherence
• Patient has difficulty bringing up problems with treatment/adherence
• Patient uncertain about provider’s ability to help
• Patient lacks trust/comfort with provider
• Patient dissatisfied with provider

Factors related to the clinical setting:
• Poor accessibility of services (e.g., availability of staff, hours of operation, wait/lines for services, etc.)
• Lack of continuity/cohesiveness of care
• Concerns about confidentiality
• Lack of child care
• Unfriendly/unhelpful staff
• Poor reputation of clinic
Features of the disease:

• Disease not serious or threatening to health
• Long-term duration of disease
• Lack of symptoms experienced by patient
• Symptoms of disease interfere with adherence (e.g., cognitive deficits, lack of mobility, problems
with vision, etc.)
Note. Factors taken from the following reviews of the literature on treatment adherence: Dunbar-Jacob & Mortimer-
Stephens, 2001; Fincham, 1995; Ickovics & Meisler, 1997; Meichenbaum & Turk, 1987; Morris & Schulz, 1992; Myers &
Midence, 1998; Shumaker, Schron, Ockene, & McBee, 1998; Vermeire, Hearnshaw, & Van Royen, 2001. Organization of
these factors is based on model of adherence developed by Ickovics & Meisler, 1997.
summarizes factors that have at least some empirical support for their association to poor
adherence to medications. Several themes appear to emerge from this literature. First, medication
adherence appears to be complex and multidetermined. That is, many different types of factors
can impact patients’ adherence to medications, including factors related to the patient, disease,
treatment, provider, and clinical setting. Second, patients appear to be quite heterogeneous in terms
of if and how any of these factors will impact their adherence. For example, depression is a factor
that has been found to have a strong association with rates of medical treatment adherence (DiMat-
teo, Lepper, & Croghan, 2000). However, this does not mean that every patient who is depressed
will have poor adherence. Additionally, for patients experiencing depression that is affecting their
adherence, this effect could be occurring for a number of reasons related to depression (e.g., sleeping
through doses, apathy about life, fatigue, problems with memory, social isolation, etc.). Third, these
factors do not provide a reliable means for predicting whether any one patient will adhere
adequately to a regimen.
Putting these themes together suggests that conducting a thorough assessment of potential
barriers and developing an individualized adherence plan with each patient is warranted. Despite
the limitations of the barriers-to-adherence literature, it can serve to facilitate this process by
orienting clinicians to potential barriers to patients’ adherence, as well as to potentially effective
interventions. The Prescriptive Adherence Counseling and Education (PACE; Levensky & O’Donohue,
2002) intervention described later in this chapter provides an example of how these factors can be
used in this way.
Interventions for Increasing Medication Adherence

The effectiveness of interventions to increase medication adherence is also somewhat unclear. This
is because a relatively small number of studies have been conducted examining these interventions
(see Haynes et al., 2002 for a review of this literature). Additionally, interpreting the results of these
studies is difficult because of methodological problems in many of the studies, including inaccurate
measures of adherence, lack of control groups, confounding variables, small sample sizes, short
follow-up periods, lack of detailed descriptions of the interventions, and differing definitions of
adherence across studies (Haynes et al., 2002). Another problem that has made it difficult to draw
conclusions from this literature is that methodologically sound studies of similar interventions have
produced different outcomes (e.g., Haynes, Wang, & Da Mota Gomes, 1987).
Despite these limitations, however, the results of these studies have generally suggested that
(a)no single strategy is clearly most effective, (b) multicomponent interventions are generally more
effective than single-strategy interventions, (c) interventions that involve multiple sessions or
follow-ups are more effective in sustaining adherence over time than one-time interventions, and
(d) the impact of these interventions is generally modest, with effect sizes rarely exceeding 0.34
(Haynes et al., 1987, 2002; Haynes, McKibbon, & Kanani, 1996; Morris & Schulz, 1992; Roter et al.,
1998). These findings are consistent with the notion that adherence involves a complex and mul-
tidetermined set of behaviors that are not easily changed.
Interventions found to be effective generally include educational, cognitive, and behavioral com-
ponents. The primary strategies used in these effective interventions are summarized in Table 18.2.
It should be noted that many of these strategies have been evaluated as part of multicomponent
interventions and have not been examined as stand-alone interventions.
Measuring Adherence to Medications

An important component in facilitating mediation adherence is identifying when a patient is
having trouble with adherence. There are a number of methods for accomplishing this. Each
method has its relative strengths and weaknesses in terms of reliability, validity, utility, and practi-
cality, and there is no gold standard for measuring adherence. Andrews and Friedland (2000),
Dunbar (1984), Miller and Hays (2000), Rand and Weeks (1998), and Vitolins, Rand, Rapp, Ribisl,
and Sevick (2000) provide useful reviews of the literature on methods of assessing medication
adherence. The descriptions below are taken primarily from these reviews.
Self-Report
Self-report is the most commonly used method of assessing adherence in clinical practice because
this method is relatively quick, easy, and inexpensive. Common methods of obtaining self-report
data include questionnaires, medication diaries, and interviews. Although self-report is the
most practical method of adherence assessment, the accuracy of this method is often reduced by
patients’ hesitancy to report missed doses and by limitations in patients’ ability to recall missed
doses (Rand & Weeks, 1998). Specifically, self-report tends to overestimate rates of adherence.
When compared with more accurate methods of measuring adherence (e.g., Medication Events
Monitoring System Caps, see below), self-report has generally been found to be a 20% overestimate
of adherence (Andrews & Friedland, 2000).
Despite these limitations, however, self-report can be a valuable clinical tool, and it has been
found to be a predictor of adherence and clinical outcomes (Rand & Weeks, 1998; Stone, 2001).
In addition, an important advantage of the self-report method over some of the other methods
(e.g., pill counts) is that it can provide information about the patterns and timing of pill taking as
well as information about barriers to adherence. This can be particularly the case when patients
keep daily medication diaries. Additionally, although self-report tends to produce overestimates of
adherence, the method does tend to have good specificity for nonadherence. That is, if patients indi-
cate they are nonadherent, this is likely to be the case (Vitolins et al., 2000). Methods that have been
shown to increase the accuracy of patient self-report of adherence include (a) using brief, struc-
tured questionnaires, (b) asking patients to report on levels of nonadherence rather than on levels
of adherence, (c) specifying a time frame, (d) assessing a recent time frame (e.g., no more than the
TABLE 18.2 Strategies for Increasing Adherence to Medication in Chronic Illness Populations
Assessing to readiness to begin treatment
• Assessing past adherence patterns and current health beliefs/concerns about the treatment
• Discussing pros and cons of initiating treatment
• Using a “practice trial” with jelly beans or other nonactive medication analogue
• Assessing for potential barriers to treatment and intervening on these
• Waiting to initiate treatment until the patient is ready
Increasing treatment-related knowledge:

• Educating patient on the:
• nature of disease
• action of the treatment
• requirements of the treatment regimen
• importance of adherence
• nature and management of side effects
• Using simple, understandable language
• Using visual aids
• Assessing comprehension
• Providing all information in written form
• Having patient demonstrate proficiency
Increasing adherence skills:

• Providing regimen-related organizational and memory-aid tools/skills including:
• special packaging (e.g., blister packaging)
• pillboxes/medication organizers
• alarms
• cues for dosing (e.g., notes and stickers)
• linking medication taking to daily activities such as morning/bedtime routines, meals,
television shows, etc.
• teaching self-monitoring (e.g., use of pill diary or calendar)
• helping patient adjust daily routine to better fit regimen
• Teaching skills on how to respond to slips in adherence
• Teaching problem-solving skills
• Improving patient’s communication with provider, including:
• asking questions
• reporting problems with treatment such as side effects, adherence, etc.
• Planning for medication-taking on a typical day, as well as nontypical days, such as weekends,
vacations, nights out, etc.
• Role playing
Increasing resources and support:

• Referring to social services/social worker for assistance with accessing resources (e.g., financial,
housing, transportation, childcare, etc.)
• Increasing social support, including:
• support group/individual counseling
• medication “buddy”
• telephone “check-ins” from staff
• help with medication taking from friends or family

Increasing motivation:
• Simplifying regimen as much as possible (few pills/dosing times, long acting medication, few food
restrictions, convenient dosing times, etc.)
• Tailoring regimen to fit patient’s lifestyle
• Working with patient to fit regimen into daily routine (e.g., setting up dosing schedule, food
requirements to match routines)
• Having patient take an active role the treatment planning and decisions
• Reframing problematic health beliefs and beliefs about the treatment
• Getting firm commitment from patient regarding specific adherence behaviors
• Establishing reinforcement system for adherence (e.g., social, financial, other tangible
reinforcements)
• Orienting patient to benefits of adherence and costs of nonadherence (e.g., on health, future
goals, etc.)
• Providing feedback to patient regarding the impact of his or her adherence and nonadherence on
clinical outcomes
• Enhancing patient’s self-efficacy
• Treating mental health problems (e.g., depression, substance abuse)
• Treating side effects
• Minimizing barriers at clinic (long waits, scheduling problems, limited appointment times, etc.)
• Using Motivational Interviewing techniques with patient (Miller & Rollnick, 1996)
Follow-up:
• Implementing telephone reminders, check-ins regarding problems with treatment/adherence
• Scheduling regular follow-up visits with patient
• Directly assessing for barriers to adherence and problem solving methods of overcoming identified
barriers on regular basis
Note. Strategies were taken from the following reviews of the literature on treatment adherence: Dunbar-Jacob &
Mortimer-Stephens, 2001; Fincham, 1995; Haynes, McDonald, Garg, & Montague, 2002; Ickovics & Meisler, 1997;
Meichenbaum & Turk, 1987; Mullen, Green, & Persinger, 1985; Myers & Midence, 1998; Roter et al., 1998; Shumaker,
Schron, Ockene, & McBee, 1998; Vermeire, Hearnshaw, & Royen, 2001.
past 7 days of medication taking), (e) using cues to facilitate recall, (f) having patients keep a medi-
cation diary in which they record their daily medication taking, and (g) reassuring patients that
problems with adherence are normal, they will not be punished for nonadherence, and that accu-
rate reporting of adherence problems is crucial for effective treatment (Andrews & Friedland, 2000;
Dunbar-Jacob et al., 1995; Rabkin & Chesney, 1999; Stone, 2001; Vitolins et al., 2000). Four brief
yes-or-no questions that have been found to be good predictors of clinical outcomes are: (1) Do
you ever forget to take your medicine?, (2) Are you careless at times about taking your medicine?,
(3) When you feel better do you sometimes stop taking your medicine?, and (4) Sometimes if you
feel worse when you take the medicine, do you stop taking it? A “yes” to any of these questions indi-
cates a problem with adherence (Morisky, Green, & Lavine, 1986).
Pill Counts
Another fairly common method for assessing patient adherence to medications is pill counts.
Doing pill counts involves determining how many pills a patient should have left, (given the
number of days since the prescription was filled and the number of pills to be taken each day),
counting all the patient’s medications to determine how many pills the patient currently has, and
then calculating the difference between how many pills the patient should have and the number of
pills the patient actually has. A strength of this method is that it can be more objective than report
in that it does not rely on a patient’s memory of missed doses. For clinical use, this method is lim-
ited by the requirements of patients bringing in all of their medications and of clinical staff taking
the time to count the pills. The accuracy of this method is limited by patients failing to bring in all
of their pills (e.g., forgetting to bring in pills not kept in bottles, or intentionally leaving pills at
home to appear adherent). Additionally, this method does not provide information about the pat-
terns of adherence and nonadherence (e.g., timing of doses, when doses were missed, etc).
Assessing patients’ pharmacy records (i.e., determining if refills were obtained on time) has also
been used in research and clinical settings as an objective measure of adherence. This method has
many of the same drawbacks as pill counts; however, it tends to be a less sensitive measure and can
be difficult to use with patients who go to more than one pharmacy to fill prescriptions.
Medication Event Monitoring System (MEMS) Caps

MEMS caps are rarely used in clinical practice owing to their expense, but are frequently used in
research because of the relatively high accuracy of the method (e.g., Liu et al., 2001). MEMS caps
are electronic devices that serve as caps to patients’ medication bottles. These caps log the date and
time of every opening and closing of the medication bottles. This information can then be down-
loaded and examined by the clinician to assess rates and patterns of adherence and nonadherence.
Strengths of this method are that it does not rely on patient report, and that it is more convenient
for both the patient and the clinical staff than is the pill count method. Additionally, it provides
information about the timing of medication taking. Disadvantages of the method are that the caps
are rather expensive (between $80 and $100 per cap), and that it cannot be determined whether a
patient actually took pills out of the bottle when it was opened, how much was taken out, or if the
patient actually consumed the medication if it was taken out. An additional disadvantage of MEMS
caps is that they are not compatible with patients using pillboxes or otherwise storing medications
outside the capped bottles.
Biological Indicators
Biological markers are used in both clinical and research settings to assess patient adherence to
medications. Typically, this involves taking blood or urine samples and assessing these for correlates
of the presence of the medication, or for traces of the medication itself. Although this method is an
objective measure of adherence, its accuracy can be affected by a number of factors such as recency
of ingestion, individual differences in absorption, and the presence of biological elements other
than the medication that can influence readings (Miller & Hays, 2000). Additionally, this method
can be expensive and impractical, and such measures are not available for many medications.
Many researchers and clinicians advocate using a combination of these methods, although it is
not yet clear how this can be done most effectively (Rand & Weeks, 1998). The use of self-report in
combination with a more objective measure, such as pill counts or assessing pharmacy records,
would likely be useful and feasible in many clinical settings.
Prescriptive Adherence Counseling and Education (PACE) Intervention

Levensky and O’Donohue (2002) have developed the Prescriptive Adherence Counseling and
Education (PACE) intervention, an individualized assessment-based HIV medication adherence
enhancement intervention. The PACE intervention has been found to produce modest, yet signifi-
cant, improvement in rates of self-reported adherence to HIV medications at 2- and 12-week
follow-ups as compared with treatment as usual, and was also found to have high patient satisfac-
tion and follow-though with the adherence plans (Levensky et al., 2002).
The PACE intervention is described in detail here to serve as a set of guidelines that behavioral
health-care clinicians working in primary care settings can use to facilitate patients’ adherence to
long-term medication regimens. Although this intervention was developed for and evaluated with
HIV patients, it is hypothesized that the principles and strategies described here can be implemented
successfully with other chronic illness populations. The PACE intervention has been evaluated using
only a clinical pharmacist to deliver it; however, the intervention was designed to be effectively deliv-
ered by most health-care providers, including nurses, pharmacists, health-care educators,
and behavioral health-care clinicians. Additionally, the intervention was designed to be delivered in a
one-on-one counseling session, but could, at least theoretically, be delivered in a group format.
The PACE intervention is designed to (a) aid clinicians in identifying important, causal,
and changeable barriers to individual HIV patient’s medication adherence, (b) guide clinicians in
developing and implementing effective tailored interventions for these identified barriers, (c) be
trainable and usable for a broad range of HIV clinicians (e.g., doctors, pharmacists, nurses, social
workers, health advocates, etc.), and (d) be acceptable, efficient, cost effective, and practical in a wide
range of HIV and primary care treatment settings (e.g., specialty clinics, hospitals, community health
centers, pharmacies, private offices, etc.). A primary assumption of the PACE intervention is that the
ability to adhere is not a patient “trait,” but rather adherence is a set of behaviors that can be facili-
tated by increasing information, skills, tools, and resources and by decreasing environmental barriers.
The content of the PACE intervention is based on a guiding model of adherence. This guiding
model organizes the determinants of HIV medication adherence into four theoretical factors:
1. Adherence-related knowledge and skills (e.g., knowledge of specific requirements of the

regimen and importance of adherence, organizational and memory-aid skills, assertiveness
skills with treatment provider).
2. Resources and lifestyle (e.g., stability of housing, transportation, and finances; social
support; match between medication regimen and daily routine; health status; depression;
substance abuse).
3. Direct rewards and punishers of adherence (e.g., responses of social network and medical
staff to adherence and nonadherence, side effects, reminder of illness, stigma, barriers at the
clinic).
4. Beliefs about HIV and the treatment (e.g., one’s beliefs about the need for treatment,
effectiveness of treatment/provider, relative costs and benefits of adherence, one’s ability
to adhere).
The PACE intervention consists of four components: (1) the Barriers to HAART Adherence
Questionnaire (BHAQ), (2) the intervention guidelines, (3) the adherence planning sheets,
and (4) a manual for using these components. The intervention is relatively brief, taking about
40–50 minutes to complete (once the patient has completed the BHAQ). Each of the intervention
components is described below.
Barriers to HARRT Adherence Questionnaire (BHAQ)

The BHAQ is a self-report questionnaire (using both written and Likert scale responses) that is
designed to assess for current and potential barriers to individual HIV patient’s adherence to HIV
medications. The BHAQ consists of 46 items, which assess for 14 adherence “domains” related to
the model of adherence described above. These barrier domains are:
1. Knowledge of prescribed HIV medication regimen.

2. Appropriateness and complexity of the prescribed medication regimen.
3. Adherence-related lifestyle, skills, and resources.
4. Responses to slips in adherence.
5. Social support.
6. Recreational drug use.
7. Alcohol abuse.
8. Depression.
9. Health and functional problems.
10. Missing doses to avoid adverse consequences.
11. Side effects from HIV medication.
12. Adherence barriers at the clinic.
13. Relationship with or beliefs about provider at clinic.
14. Beliefs about HIV and HIV medications.
Three additional items on the BHAQ assess current adherence to the medication, and ask patients
to identify additional barriers to their adherence as well as facilitators of their adherence.
Patients complete this questionnaire before meeting with the adherence counselor. If a patient is
not able to read, the clinician reads the questions and response choices to the patient and records
his or her answers. The adherence counselor then examines the completed BHAQ for potential
adherence barriers, which are easily identified by a quick scan of the patient’s responses on the
questionnaire’s Likert scales. The BHAQ has not been psychometrically evaluated because it
consists of a set of face-valid items intended to alert the clinician to potential adherence barriers,
which he or she is then guided in further assessing.
Intervention Guidelines
The intervention guidelines are designed to guide adherence counselors in designing individualized
plans for addressing the adherence barriers that have been identified on the BHAQ. The content
of these guidelines is guided by the model of adherence described above, and they incorporate
strategies and techniques shown to be effective in producing health behavior change or are compo-
nents of effective health behavior change interventions (e.g., Meichenbaum & Turk, 1987; Safren
et al., 2001; Shumaker et al., 1998). These include
1. Providing information regarding the nature of HIV/AIDS, HAART, the requirements of the
regimen, and the importance of adherence.
2. Increasing adherence-related skills such as stimulus control strategies (i.e., use of cues for
medication taking), self-monitoring, organization, fitting the regimen into the daily
routine, communicating with providers, and anticipating, preventing, and dealing with slips
in adherence. Also included is providing medication organizers, diaries, and reminder
alarms as needed.
3. Increasing resources and support, such as practical and emotional social support
(e.g., obtaining help with medication taking, going to support groups, increasing contact
with exiting social network), and financial, housing, transportation, and food resources
(through referrals to social services).
4. Increasing motivation (i.e., increasing reinforcement and reducing punishment), such as
orienting patient to benefits of adherence and costs of nonadherence, providing feedback on
the impact of the patient’s adherence on his or her health status, increasing the patient’s
sense of adherence self-efficacy, increasing social reinforcement for adherence, treating
medication side effects and other health problems, providing treatment for depression and
substance abuse, addressing fears about the medication, and simplifying and tailoring the
regimen to fit one’s lifestyle.
The manual for delivering the intervention includes instructions for the clinician in the use of
general counseling methods found to be effective in producing health behavior change.
These counseling methods are used throughout the intervention: skills training (O’Donohue &
Krasner, 1995), behavior modification (Epstein & Cluss, 1982), problem solving (D’Zurilla, 1986),
Motivational Interviewing (Miller & Rollnick, 2002), increasing self-efficacy (Bandura, 1986), com-
mitment strategies (Linehan, 1994), and behavioral contracting (Kirschenbaum & Flanery, 1983).
Some of these same counseling techniques were employed in another HAART adherence interven-
tion recently found to produce some promising results (Safren et al., 2001).
Additional important aspects of the manual are that it instructs the counselor in (a) assessing
if and how an identified barrier actually functions to interfere with a patient’s adherence to the
medications, (b) developing plans both to reduce identified barriers to adherence and to improve
adherence despite persistent barriers, and (c) working collaboratively with the patient in developing
the adherence plans.
The intervention guidelines consist of 14 separate, one-to-three-page guidelines, each of which
is specific to one of the adherence barrier domains assessed for in the BHAQ (i.e., knowledge
of prescribed HIV medication regimen, adherence-related lifestyle, skills, resources, etc.). An inter-
vention guideline for a specific barrier domain is followed when at least one of the items represent-
ing that domain has been sufficiently endorsed on the BHAQ. For each barrier domain, there are
both “general guidelines” and “specific guidelines.” The general guidelines are followed when any of
the BHAQ items representing that domain have been endorsed. The specific guidelines are followed
in addition to the general guidelines and are followed only when specific BHAQ items representing
that domain have been endorsed.
Adherence Planning Sheets

The adherence planning sheets are intended as a record of the adherence plans that have been
developed. There is one adherence planning sheet for each intervention guideline. After the adher-
ence counselor and patient have agreed upon an adherence plan for a particular barrier domain, the
patient is asked to record the plan on the appropriate adherence planning sheet. A completed
adherence planning sheet describes all the important details of each adherence plan (e.g., how,
what, were, when, why, etc.). Once all of the necessary BHAQ intervention guidelines have been
followed, and all the necessary adherence planning sheets have been completed by the patient, the
adherence counselor staples the adherence planning sheets into a booklet and gives this booklet to
the patient to take home.
Specific PACE Assessment and Intervention Strategies

The following is a brief summery of the PACE assessment and interventions strategies for each of
the adherence domains. The general counseling principles mentioned above are followed when
implementing these strategies.
Knowledge of the Regimen
Assessment. Patients are asked to list the name of each medication they are prescribed and to indi-
cate for each medication (a) the color and shape of the pills, (b) the number of pills taken at each
dose, (c) the number of doses take each day, (d) the times of day does are to be taken, and (e) any
special dosing instructions (e.g., with food or on an empty stomach). These questions were based
on the AIDS Clinical Trials Group’s (ACTG) medication adherence measure (Chesney et al., 2000).
The patients’ reports of their regimens are then compared with the prescribed regimen as indicated
in the patient’s chart.
Interventions. If there is a discrepancy between a patient’s report of his or her regimen and the
regimen documented in the chart, this discrepancy is pointed out to the patient, and the adherence
counselor determines if the patient has made an error in documenting the regimen or is mistaken
about the actual regimen requirements. If necessary, the adherence counselor consults with the
patient’s prescribing provider to get the patient back on the correct regimen. The patient is given
written instructions for the correct regimen, including: (a) the names of the medications, (b) the
color and shape of the pills, (c) the number of pills taken at each dose, (d) the number of doses
taken each day, (e) the times of day doses are to be taken, and (f) any special dosing instructions
(e.g., food and fluid restrictions).
Adherence to the Regimen
Assessment. Patients indicate how many doses of each prescribed medication they have missed on
each day of the last week, and also rate on a 5-point Likert scale how frequently they have taken
doses at the correct times and followed the special dosing instructions. The taking of partial doses is
counted as missing a dose. Patients also make a more general rating of the frequency of missed
doses in the past month. These questions were also based on the ACTG medication adherence
measure (Chesney et al., 2000). The adherence counselor further assesses for patterns of nonadher-
ence, including the times of day, particular days of the week, and specific types of situations, places,
or people that precipitate problems with adherence. In this assessment, patients are asked to
identify all the possible reasons they can think of for their missed doses. Patients are also often
asked to identify a recent incident of a missed dose and to identify factors that contributed to this
lapse in adherence. Commonly reported reasons for missed doses reported by patients include
(a) simply forgetting, (b) sleeping through doses, (c) being away form home and not having the
medication with them, (d) having a change in the daily routine, (e) being busy with other things,
(f) feeling too sick or experiencing side effects, (g) feeling depressed, and (h) feeling good (Leven-
sky et al., 2002). The extent to which nonadherence is intentional is also assessed.
Interventions. Adherence barriers identified by the patient here are noted and addressed by
following one or more of the appropriate assessment and intervention guidelines described below.
Appropriateness of the Regimen
Assessment. The extent to which the prescribed medication regimen is the most appropriate possible
for the patient is assessed. Specifically, the prescribed regimen is reviewed with three primary
questions in mind.
• Is the prescribed medication the most effective treatment available for the patient?
• Is there an alternative, but equally effective, medication option that involves fewer pills at
each dose, few doses, easier administration (e.g., easier to swallow), fewer food restric-
tions, or fewer (or less severe) side effects?
• Would it be possible to modify the dosing schedule of the currently prescribed medication
to reduce its complexity and demands?
Interventions. If it appears that the medication regimen should be changed, simplified, or otherwise
made less demanding, the clinician works with the patient and the prescriber to make these adjust-
ments. The prescribing provider is consulted before a medication change is discussed with the patient.
Social Support
Assessment. The nature and quality of the patient’s social support system is assessed, including the
extent to which (a) important people in the patient’s life know about his or her diagnosis and are
supportive of the patient in taking the medication, (b) the patient has help with taking the medica-
tion (e.g., reminders, reinforcement, etc.), (c) the patient has people he or she can go to for general
emotional and practical support, and (d) the patient is satisfied with these supports.
Interventions. The importance of social support in facilitating adherence to a long-term medica-

tion regimen is discussed with the patient. Depending on the identified needs of the patient, and
the patient’s willingness, interventions to increase social support include (a) encouraging and prob-
lem-solving with the patient to solicit support (e.g., emotional/practical support, help with taking
medications, etc.) from existing friends and family members, and (b) increasing the patient’s
support network, including referring the patient to a support group or treatment advocate (an indi-
vidual who regularly checks in with and supports the patient regarding adherence). An effort is
made to identify at least one person (e.g., spouse, partner, friend, roommate, etc.) who can help
with adherence. The patient may also be encouraged to tell appropriate individuals about his or her
diagnosis so that the patient can get support around this issue.
Beliefs About the Disease and Treatment
Assessment. The patient’s beliefs about his or her disease and about the prescribed medication
are assessed in several domains based on the Health Beliefs Model (Janz & Becker, 1984). The belief
domains assessed are (a) the likelihood of the disease worsening if left untreated, (b) the seriousness
and threat of the disease to the patient’s health, (c) the patient’s ability to adhere to the medications,
(d) the effectiveness of medication in treating the disease, (e) the relative costs and benefits
of taking the medications, and (f ) the necessity of taking the medication as prescribed for the
treatment to be effective. If the patient indicates problematic beliefs in any of these domains, the
specific nature of these beliefs is further assessed.
Interventions. Interventions for problematic beliefs include providing information about

the progression of the disease if untreated and the importance of adherence to the medication.
Additional interventions include orienting the patient to the benefits of adhering by helping the
patient identify his or her long-term goals and values and relating these to adherence. If other
adherence barriers are identified during the assessment of the patient’s beliefs (e.g., lack of skill,
depression, inadequate social support, side effects, etc.) the intervention guidelines for these other
barriers are followed. The patient may also be referred to an HIV support group or medication
“buddy” so that adherence-promoting beliefs can be reinforced.
Adherence-Related Lifestyle, Resources, and Skills/Tools
Assessment. Three domains are assessed to determine the extent to which they interfere with
adherence: (1) the fit between the patient’s lifestyle (e.g., eating and sleeping patterns, work
schedule, activities, etc.) and the requirements of the regimen, (2) the patient’s practical resources
for day-to-day living, and obtaining and adhering to the medication (e.g., money, food, housing,
transportation, medication storage, etc.), and (3) the effectiveness of the patient’s medication
organizational or memory-aid system (e.g., patient’s ability to remember to take doses on time both
on typical days and on nontypical days such as weekends, nights out, and vacations). The extent to
which these factors impact adherence is often assessed by having the patient describe a typical day
of adherence and a typical day of nonadherence and by discussing the specific types of circum-
stances in which doses have been missed. Additionally, the effectiveness of the patient’s medication
organizational or memory-aid system is evaluated by assessing the extent that doses are missed
because of forgetting to take the dose, forgetting whether doses have been taken, being away from
home and not having the medication available, running out of medication, sleeping through doses,
being too busy, and having changes in daily routines. Also, the extent to which these factors affect
the patient’s taking medications at the correct times and following the food and liquid require-
ments is assessed.
Interventions. If a poor fit between the patient’s daily routines and the requirements of the regimen
appear to be affecting adherence, several interventions are considered. These include (a) discussing
the usefulness and feasibility of maintaining regular bedtimes, wake-up times, and meal times so
that these activities can serve to cue dosing and aid the patient in following dietary requirements for
dosing, (b) problem solving with the patient on steps he or she can take to make these activities
more regular, (c) problem solving with the patient on how to best adhere within the context of a
variable schedule of activities, and (d) considering making modifications in the medication
regimen or switching regimens to better fit the patient’s lifestyle (e.g., switch to a different type of
medication or to a longer-acting version of the same medication to reduce number of doses).
Making medication changes is always discussed with the patient’s prescribing provider. It is worth
noting that in some cases, it may be more effective to have the patient take a less optimal medica-
tion that he or she will be more likely to actually take correctly than a more optimal medication to
which the patient will not adhere.
If the patient indicates that a lack of specific practical recourses is impeding adherence, interven-
tions include problem solving on how the patient can obtain these recourses or can adhere without
them. The patient may be referred to a social worker for assistance in obtaining needed resources.
Additionally, making a change in the medication regimen may be considered (e.g., medications that
are less expensive, do not have food requirements, and do not need to be refrigerated).
If a lack of memory or organizational skills or tools is identified, these tools and skills are
provided to the patient, including pillboxes, alarms, stickers and notes, self-monitoring sheets or
diaries, and strategies for linking doses to daily activities. The provision of these skill and tools is
frequently included in the PACE intervention and is, therefore, described in some detail here.
A pillbox can be a very useful tool to enhance patient adherence, and pharmaceutical companies
usually will provide them for no charge. These medication organizers are typically designed to hold
doses for an entire week, with separate compartments for morning, afternoon, and evening doses,
and allow patients to remove each daily compartment so that it can be carried with them. These
organizers not only facilitate patients’ taking the correct medications at each dose, but also can
remind patients whether or not doses have been taken. If a pillbox organizer is provided to a
patient, the patient is instructed in how to fill and use it, and is asked to demonstrate this to the
clinician. Additionally, a plan is made to fill the pillbox on a specific day each week. For medica-
tions that need to be refrigerated or kept in their original containers, small items such as candies
serve as placeholders in the pillbox. Some long-term medications have begun to be available in blis-
ter packs, which preorganize doses for each day, and can serve similar functions as a pillbox.
Also commonly available at no cost from pharmaceutical companies are alarms that can be
programmed to prompt patients to take medication doses at the appropriate times throughout
the day. These alarms come in wristwatch and pocket formats and can serve to both remind
patients to take doses and confirm whether or not doses have been taken. Not all patients are will-
ing to use these alarms, or for that matter would benefit from them; however, all patients are
informed that they are available and oriented to the usefulness of these devises. Patients may also
have digital watches that can be used for this purpose, and prefer to use those. As with pillbox
organizers, patients who are provided dosing alarms are instructed in their use and are asked to
demonstrate proficiency.
Other useful memory-aid tools are stickers (e.g., colored dots) and notes to cue dosing
(e.g., Safran et al., 2001). These cues are placed in locations where they are most likely to be seen at
dosing times, such as on the bathroom mirror, coffee machine, television, alarm clock, the refriger-
ator, or the desk or computer at work. Stickers or notes can also be placed next to the front
door and in the car to remind patients not to forget to bring needed medications when leaving
home. Keeping the medications in locations where they will be readily seen can also serve as a cue
for dosing.
Another strategy that can be used to aid patients in reducing missed doses is self-monitoring
(Southam & Dunbar, 1986). This procedure often involves having patients record the time doses
have been taken each day, as well as the number of pills that were taken at each dose, whether or not
special dosing instructions were followed, and reasons for missed doses. Common methods for self-
monitoring include the patient’s keeping a medication diary or recording medication doses on a
calendar. This can be made relatively easy by teaching the patient to use basic symbols (e.g., a
checkmark or an X) in the diary or calendar to indicate whether doses have been taken. In addition
to the possible benefits of reminding patients if doses have been taken, this type of self-monitoring
can have the additional benefit of providing information to the clinician on the patterns of the
patient’s medication taking, as well as times of day and situations in which adherence problems
occur. This information can be used by the clinician to problem solve with the patient on ways to
increase adherence.
It can also be useful to teach patients to link taking medication to regular daily activities.
This involves identifying activities that the patient engages in at regular times each day that corre-
spond to dosing times, and using these activities as cues to take medication doses. Common exam-
ples of such activities include getting out of bed in the morning or getting in bed at night, regular
meals, television shows, and toothbrushing or other regular hygienic activities. Patients are often
asked to take their medications before doing these activities so that they will be less likely to forget
to take the medication and may be rewarded for taking it.
Once the above adherence tools and skills have been discussed and the patient has decided which
ones he or she will use, a specific and detailed plan for taking medication on typical days is devel-
oped. This involves identifying the components of the patient’s typical day (waking up, getting
showered and dressed, eating breakfast, going to work, coming home, etc.), and putting together
the agreed-upon adherence skills and tools into a comprehensive and concrete plan for taking the
medications throughout the day. Potential barriers to adherence on these typical days are identified
and solutions for overcoming them are developed. Adherence plans for nontypical days (e.g., week-
ends, vacations, trips, parties, etc.) are also developed (see Safren, Otto, and Worth, 1999, for exam-
ples of these strategies). Plans are also made for when and how medication refills will be obtained.
Key elements of these plans focus on how the patient will be reminded to take doses at correct times
and how the patient will have access to the correct medications at those times. As with other adher-
ence plans, these plans are provided the patient in writing.
Communication With and Beliefs About Prescribing Provider
Assessment. Areas assessed to identify possible problems with the patient-provider relationship
include the extent to which the patient (a) believes the provider has the ability to help him or her,
(b) trusts the provider, (c) can communicate with the provider (e.g., bring up problems with side
effects, adherence, etc.), (d) feels understood by the provider, (e) believes the provider cares about
him or her, (f) feels that he or she gets enough time during a visit with the provider, and (g) is
satisfied with the treatment he or she is receiving from the provider.
Interventions. If identified problems with the patient-provider relationship appear to be interfer-

ing with adherence (e.g., decreasing the patient’s motivation to adhere, preventing the patient from
asking questions or bringing up problems), the interventions carried out include (a) discussing
with the patient the importance of the patient-provider relationship (e.g., trusting the provider,
getting questions answered, bringing up problems, etc.), and (b) providing the patient with basic
skills for communicating effectively with his or her prescribing provider. These latter skills include
(a) bringing a list of questions to appointments and asking them directly, and (b) informing
the provider about side effects, difficulties with adherence, or other problems with the treatment.
Role-playing with the patient is often used to teach these skills. Some patients feel uncomfortable
with being assertive with their provider. This discomfort is assessed for and addressed. One solution
to this is to have the patient bring an advocate (spouse, friend, family member) to the medical
appointment to offer support in giving information to, and obtaining information from, the pro-
vider. In cases where patients feel quite dissatisfied or uncomfortable with their provider,
consultation with the provider or switching to a new provider is implemented.
Adherence Barriers at the Clinic
Assessment. Current and potential barriers to the patient’s adherence existing at the clinic are
assessed. These may include difficulty in getting appointments at convenient times or when they
are needed, long waits, concerns about confidentiality, difficulty obtaining refills, poor reputation
of the clinic, and unfriendly or unhelpful staff.
Interventions. Interventions include problem solving with the patient on how to be assertive with
staff to get needs met (using role playing as appropriate) and getting needs met despite these barriers.
Additionally, consultation with staff to reduce these barriers is done as appropriate.
Missing Doses to Avoid Unpleasant Consequences
Assessment. Several types of potentially aversive consequences for taking medications, as well as the
extent to which these consequences are interfering with adherence, is assessed. The consequences
assessed are both actual consequences for taking the medication, as well as those that are antici-
pated by the patient. These include: (a) side effects of the medications, (b) difficult administration
(e.g., hard to swallow, bad taste of medication, etc.), (c) not wanting others to notice the patient
taking the medication (i.e., wanting to avoid stigma, or others knowing about the patient’s illness),
(d) worries that the medication will be harmful to the patient, (e) not wanting the medication to
interfere with activities (e.g., drinking alcohol, eating certain foods, etc.), and (f) not wanting to be
reminded of the illness. Additionally, the extent to which symptoms of the patient’s current health
or physical problems (e.g., fatigue, decreased mobility, etc.) make it difficult to take the medications
as prescribed is assessed, as well as whether patients miss doses because they are “feeling good.”
Interventions. Interventions involve problem-solving with the patient to reduce the identified
aversive consequences of adherence. Common solutions include (a) working with the patient’s pro-
vider to treat side effects, (b) helping the patient think about untreatable side effects as “signs that
the treatment is working,” (c) reframing thoughts of medications as a reminder that the patient is ill
to a reminder that the patient is treating the illness, (d) teaching the patient how to take his or her
medications more discretely when in public, (e) helping the patient prepare answers to unwanted
questions from others about the purpose of the medications, (f) educating the patient on the con-
sequences of missing doses, and (g) considering a change of medication to make administration
easier or to reduce side effects. The clinician also works on helping the patient orient to the value of
taking the medication, despite the aversive consequences, by having the patient discuss and orient
to his or her long-term goals and values (e.g., health, family, friends, etc.). These interventions typ-
ically involve both reducing the aversive consequence of adherence, as well as helping the patient
adhere with the unpleasant consequence in place. For identified, anticipated, aversive consequences
that have not actually occurred (e.g., side effects), information on the likelihood of these conse-
quences as well as the management of them is provided.
Reponses to Slips in Adherence
Assessment. Even for the best-intentioned patients with the greatest resources and skills, at least
occasional missed doses are inevitable with long-term medication regimens. When patients do miss
a dose, they can sometimes have a reduction in self-efficacy, believe they have “blown it,” and stop
trying to adhere to the medication. This phenomenon has been referred to as the abstinence viola-
tion effect (AVE; Marlatt & George, 1998). Patients are asked about this directly.
Interventions. Intervention strategies include discussing with the patient that (a) slips in adherence
are normal, (b) the important thing is to learn from the slip and return to following the regimen,
and (c) if necessary, the patient should inform his or her provider about the slip so that the patient
can receive help with getting back on the regimen.
Depression
Assessment. To assess for depression, a 5-item questionnaire developed by Burns (1997) is used. This
measure is highly correlated with the longer Beck Depression Inventory (Beck, Ward, Mendelsohn,
Mock, & Ergaugh, 1961). The five items assess for feeling “sad or blue,” “discouraged or hopeless,”
a “low self-esteem,” “worthless or inadequate,” and a “loss of pleasure.” If depression has been
identified, specific symptoms of depression that are interfering with adherence are assessed (e.g., loss of
appetite, fatigue, sleeping through doses, apathy about life, loss of motivation to take medications, etc.).
Interventions. As with other interventions, both reducing depression and increasing the patient’s
adherence while depressed are targeted. Interventions include (a) working with the patient to
increase his or her social support and other pleasant activities (i.e., behavioral activation), and
(b) referring the patient for pharmaceutical treatment, a support group, or individual or group
counseling.
Substance Abuse
Assessment. The frequency and quantity of alcohol and recreational drug use are assessed. The use
of recreational drugs is assessed by each drug type (marijuana, cocaine, opiates, and amphetamines).
The extent to which substance abuse is implicated in missed doses is assessed (e.g., forgetting, apathy,
concerns about adverse interactions, etc.).
Interventions. The issue of alcohol and recreational drug use can be sensitive. The patient is told
that the goal of the discussion about substance use is only to provide the patient information about
the possible effects of substance use on adherence and the effectiveness of the treatment (e.g., more
likely to miss doses, drug interactions, etc.). The patient is provided this information in a noncon-
frontational way, so that the patient feels free to make a choice based on the information provided.
If the patient indicates that he or she would like help with reducing substance use, he or she is
referred to individual or group therapy. If the patient indicates that he or she wishes to continue sub-
stance use, the clinician problem-solves with the patient about how he or she can adhere while using
these substances (provided that it is safe to do so). These can include taking mediations before drug
or alcohol use (to prevent forgetting), and eating and drinking fluids soon after drug or alcohol use.
Follow-Up and Maintenance

Although a follow-up component was not included in the preliminary evaluation of the PACE
intervention, such a component has been developed and will be evaluated in a study soon to
be under way. The follow-up component involves having the patient meet with the adherence
counselor 1 to 2 weeks after the initial visit, and then again after that as needed. Elements of these
follow-ups are (a) assessment of adherence, (b) assessment of effectiveness of adherence plan,
(c) reassessment of barriers to adherence, (d) reinforcing, modifying, and augmenting adherence
plan as needed, (e) reinforcement of adherence, and (f) linking adherence to health outcomes.
Integrating an Adherence Intervention Into Primary Care

The process of integrating behavioral health-care interventions into primary care settings is
discussed in detail in chapter 1 of this volume. However, several recommendations to facilitate the
integration of a medication-adherence intervention into this setting are listed below. It is recom-
mended that the behavioral health-care clinician
• Become educated on disease processes, medication treatments, and medication side effects
and their management.
• Keep primary care providers and other relevant staff informed about the intervention and
how to refer patients to it. Specifically, these providers should be informed about the
nature of the intervention, how to identify appropriate patients, and how to present the
intervention to patients. This can be done by presenting in-services, distributing flyers,
and checking-in with providers.
• Encourage primary care physicians and other relevant staff (nurses, pharmacists, health
advocates, etc.) to regularly assess patients’ adherence to medication regimens.
• Encourage primary care providers to present the intervention to patients as a standard
part of chronic illness management, rather than a service for “problem patients.”
• Regularly check with primary care providers about any patients who may be appropriate
for the intervention.
• Collect outcome data that primary care physicians can appreciate and provide it to them.
These data include the impact of the intervention on adherence rates, clinical outcomes,
service utilization, and patient satisfaction. Also assess primary care providers’ satisfaction
with the intervention. Use these data to improve the intervention.
• Keep the primary care physicians and other relevant staff informed about (a) the nature of
the patient’s adherence problems, (b) the specific barriers to adherence for the patient, and
(c) the adherence plans developed with patients and the outcomes of these plans.
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Chapter 19
The Integrated Management of Adult Asthma
MICHELLE R. BYRD, KYLE E. FERGUSON, DEBORAH A. HENDERSON,

ERIN M. OKSOL, AND WILLIAM T. O’DONOHUE
Of the aspects of heath most often taken for granted, the ability to breathe is primary. However,
for persons who suffer from chronic respiratory diseases, breathlessness is a terrifying and life-
threatening reality. This chapter will address the most common respiratory ailment throughout
one’s lifespan—asthma.
Asthma can be conceptualized as a chronic inflammation of the bronchial tubes sometimes
accompanied by respiratory distress. As yet, there is no clearly understood etiology of the dis-
ease. Individuals suffering from asthma intermittently experience such symptoms as wheezing,
coughing, and difficulty catching their breath, with varying degrees of severity (NAEPP, 1997).
Asthma is defined as a chronic disease, meaning that there is no cure, only long-term manage-
ment of the disease. The primary target of asthma management is to avoid asthma exacerbations
or attacks. Poorly managed asthma may have serious consequences, including permanent
disability and death.
Asthma is one of the most prevalent chronic illnesses, affecting approximately 14–17 million
people in the United States (CDC, 2004). Although science has made great advances in understand-
ing and treating asthma, we are not yet able to prevent the onset or effectively control the course
of the disease. In fact, the number of people affected by asthma is climbing; the national asthma
prevalence rates have risen 75% since 1980 (CDC, 2004). Asthma is now diagnosed more often than
any other illness in primary care visits, about 10 million times per year, and is the most frequently
diagnosed illness upon hospital admission (CDC, 2004). Furthermore, in addition to rising
prevalence rates, various markers of poorly managed asthma also appear to be rising, including
hospitalization rate, morbidity, and mortality (Yoos & McCullen, 1996).
The personal and societal impact of asthma is staggering. Asthma attacks result in excess of
5,000 deaths, 468,000 hospital admissions (with an average length of stay of 5 days), and 3 million
lost work days annually (CDC, 2004). Almost half of asthma sufferers report that the disease
restricts their ability to participate in daily physical activities, such as walking up stairs or playing
with their children (Collins, 1997).
A discussion of incidence and prevalence rates of asthma would not be complete without
considering the cultural context in which the disease occurs and is managed. In approximately one
367
decade, the overall death rate attributed to asthma rose 62%, with a greater increase among minority
populations and low socioeconomic inner-city populations (CDC, 2004; Dinkevitch, Cunningham,
& Crain, 1998). Specifically, African Americans have been found to have significantly higher rates
of asthma diagnosis, more asthma-related hospitalizations, and asthma-linked morbidity when
compared with nonminority samples (Blixen, Tilley, Haustad, & Zoratti, 1997). Gender must also
be considered in the diagnosis and management of asthma. Males, regardless of ethnicity, were
approximately 1.5 times more likely to die from asthma than females (CDC, 2004).
Not surprising, given the overall rates of utilization and disability, asthma costs more in health-
care dollars than any other medical condition, including hypertension and cancer (Dyer, 1999). The
direct cost of treating asthma is estimated to be $6.2 billion yearly, with the majority of that cost being
attributed to emergency department visits, hospitalizations, and death (Weiss, Gergen, & Hodgson,
1992). Direct costs also include outpatient clinic visits and multiple medications per patients.
Indirect costs of asthma appear to be relatively equal to direct costs. In 1993, direct and indirect
costs associated with asthma totaled $12.6 billion, with that figure having climbed to approximately
$14.5 billion in 2000, the most recent year for which cost estimates are available. Because asthma
affects approximately 5.2% of peak working-age people (18–44 years), losses of workdays, limita-
tions in functioning, and subsequent lost wages are also significant (U.S. Department of Health and
Human Services, 1996). The cost of lost workdays (outside the home) has been estimated to
be about $284.7 million per year (Weiss, Gergen, & Hodgson, 1992). For those who work inside
the home, the estimated economic value of lost housework is over $500 million (Weiss, Gergen, &
Hodgson, 1992). In comparison, costs related to limitations in functioning, including hospitaliza-
tions, are approximately twice in patients with asthma compared with those rates reported in
hypertensives (Collins, 1997).
Fortunately, treatments for asthma have been developed that, when properly implemented by
both clinicians and patients, can effectively manage asthma, thereby limiting the number and severity
of exacerbations and the associated increased risks of mortality, disability, and medical costs.
Because the successful management of asthma requires both physical and behavioral interventions
like many other chronic diseases, it is critical to take an integrated approach to asthma manage-
ment. Although effective technologies exist, there is a wide gap between known best practices and
the treatment of asthma as it is typically undertaken, resulting in a much lower than ideal rate of
well-managed asthma patients.
The primary goal of this chapter is to orient the reader to the integrated treatment of asthma
in the primary care setting. We will first provide a brief medical overview of the disease process
and treatment of asthma. We will then describe how asthma is managed and the role mental
health professionals might play in improving effective disease management. In particular, we
will discuss barriers to successful asthma management and suggest ways of improving response
to treatment.
Defining the Disease

Asthma is defined as a chronic inflammatory disorder of the airways characterized by symptoms
including “recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly
at night and in the early morning” (NAEPP, 1997, p. 3). Asthma typically results in airflow obstruc-
tion and an increased sensitivity to a variety of bronchial irritants such as pollen, dust, and animal
dander (NAEPP, 1997). Asthma is sometimes initially difficult to diagnose because symptoms may
present as or occur in the context of less serious illnesses, such as a common cold or bronchitis.
Several techniques are commonly used to get a complete clinical picture to make a differential
diagnosis, including obtaining a complete medical history (particularly history of asthmalike
The Integrated Management of Adult Asthma • 369
symptoms), conducting a physical examination, using spirometry to measure airflow (inhalation,

exhalation, and speed of exhalation), taking chest x-rays, and conducting allergy tests.
For the clinical practitioner or epidemiologist, the gold standard for the definitive diagnosis of
asthma is threefold: a history of recurrent symptoms (e.g., coughing, dyspnea, tightness of the
chest, and wheezing), reversible airflow obstruction assessed using spirometry, and the exclusion of
alternative diagnoses (e.g., pneumonia) (NAEPP, 1997, p. 3). In making the diagnosis, therefore,
medical providers must consider the pattern of symptoms over time rather than solely the patient’s
clinical presentation at the time of evaluation. Reversible airflow obstruction may occur spontane-
ously or in response to medications. As such, asthma is partially defined by response to treatment.
To meet the criterion for reversible airflow obstruction, the patient must have less than 65% of
expected airflow prior to treatment with an asthma medication, such as a short-acting beta 2
agonist, and an improvement of at least 12% after treatment. Other physical findings that support
the diagnosis of asthma but are not necessary for the diagnosis to be made are tachypnea, tachycardia,
the use of accessory muscles in breathing, and pulsus paradoxus.
Asthma is classified by severity, which helps determine an individualized and appropriate level of
care. The levels of classification are:
• Mild asthma (intermittent or persistent)—These patients experience either infrequent

exacerbations or persistent but mild symptoms of cough, wheezing, and dyspnea or
breathlessness. They are usually asymptomatic and have good tolerance for exercise
between attacks. They do not require urgent or emergency care. Despite decreased airflow,
their pulmonary functions are usually normal.
• Moderate asthma—These patients have symptoms intermediate between mild and severe.
• Severe asthma—These patients have daily symptoms and require urgent or emergency
treatment several times per year. Due to the chronicity of inflammation, they also respond
poorly to bronchidilators (described in more detail below).
Treating the Disease

Asthma is a well-researched problem, the focus of a huge body of literature and several journals.
Based on this literature, practice guidelines have been developed to guide health professionals in
efficiently and effectively treating patients with asthma. Before undertaking the integrated manage-
ment of asthma, it is recommended that the clinician become familiar with the best practices.
Currently, the most recognized and accepted treatment guidelines for asthma are the National
Asthma Education and Prevention Program’s (NAEPP) Expert Panel Report 2: Guidelines for the
Diagnosis and Management of Asthma (1997) (updated on selected topics in 2002), which were
coordinated by the National Heart, Lung, and Blood Institute. The NAEPP guidelines specify both
medical and psychological components for the effective management of asthma. These guidelines
provide clear recommendations for the accurate medical diagnosis, treatment, and monitoring of
asthma. In addition, the guidelines include patient education materials, treatment plan forms, and
patient diary cards to assist clinicians in implementing the guidelines and to assist with patient
education. Based on the guidelines, the Practical Guide for the Diagnosis and Management of Asthma
(NAEPP, 1997) provides more specific suggestions for creating individualized programs. Another
excellent resource is Improving Asthma Care in Children and Adults, which provides specific sugges-
tions for creating the treatment “culture” in which the NAEPP guidelines can be most effectively
implemented and tested.
The remainder of this chapter will summarize the current practice guidelines and make
suggestions to extend the existing guidelines to include more recent research findings and adapt
the recommended practices to the integrated-care environment. Although this chapter is aimed
at behavioral health professionals who are committed to treating patients with asthma, in order
to accomplish behavioral treatment goals the behavioral health provider must first have an ele-
mentary understanding of the medical management of asthma, particularly because behavioral
health-care providers may play an integral role in increasing adherence to medical protocols.
Medical Management of Asthma

Asthma is best treated in a disease management model. This model was first developed at the Mayo
Clinic in an attempt to provide a systematic process to identify at-risk patients, provide both
preventive care and intervention, and monitor short- and long-term health outcomes. Consistent
with a disease management approach, both prevention and treatment are key elements of asthma
management according to the NAEPP guidelines.
The first target of successful asthma management is avoiding (preventing) medical crises by
treating the chronic pulmonary inflammation associated with asthma. This is usually accomplished
through the use of “maintenance” medications, which can be either taken orally or inhaled. Long-
term control medications include inhaled steroids, oral steroids, and long-acting bronchodilators.
Inhaled steroids are the most potent medication currently available and are usually well-tolerated
and safe at recommended doses. Inhaled asthma medication is usually administered through a
metered-dose inhaler (MDI), which provides a controlled amount of medication. There are also
some new orally administered maintenance medications now being prescribed; however, these
medications have not yet been integrated into the current practice guidelines.
In the use of MDI, the most common maintenance-medication method of administration,
there are several important components to successful self-administration. Unlike the use of oral
agents, patients must be taught not only when to use their inhaled medications, but also how. In
particular, there are techniques patients should be taught to a level of mastery prior to being sent
home to manage their disease, such as correctly measuring distance between their mouth and
their inhaler. The form of administration should be periodically evaluated for adherence to
prescribed protocol. It must be noted that these types of maintenance medications must be taken
once to several times daily, even when the patient does not feel ill, presenting an inherent chal-
lenge to compliance.
The second component of asthma management is avoiding or limiting exposure to allergens or
other asthma triggers. Asthma may be exacerbated by a variety of triggers such as molds, animals,
smoke, exercise, respiratory infections or colds, and experiencing strong emotions (NAEPP, 1997).
Obviously, many of these stimuli cannot or should not be avoided (e.g., exercise or laughing),
however, patients must be instructed how to manage their disease when they do encounter triggers.
Behavioral health-care providers in primary care settings may be able to help patients develop self-
management plans so they are better able to prevent attacks from occurring by modifying their
environment or their response to their environment when the triggers cannot be eliminated.
In addition, there are several co-morbid medical conditions that must be monitored by both
patient and physician to predict and potentially prevent asthma exacerbations. These conditions
include allergies, smoking, rhinitis, sinusitis, gastroesophageal reflux, sulfite sensitivity, medication
interactions (for example, beta blockers and aspirin are potentially fatal in asthma patients),
occupational exposures to harmful substances, and viral respiratory infections. Although these
common medical problems may pose only minimal health risk to nonasthmatics, in this population
the common cold, left untreated, may precipitate a fatal medical event.
It is critical that patients learn to monitor their symptoms, recognize when they are likely to
have an exacerbation, and take appropriate steps to protect their airways. One of the primary
components of self-monitoring is the use of a peak flow meter. Patients should be instructed by
their health-care treatment team in the use of peak flow meters to assess respiratory function
between office visits. Monitoring peak flow is akin to hypertensive patients learning to take their
own blood pressure at home or diabetic patients learning to measure their blood glucose in order to
titrate their insulin appropriately.
Peak flow is defined as the greatest velocity of forced exhalation from fully inflated lungs. One
patient was noted to have conceptualized obtaining his peak flow as “giving it all he’s got.” Using
peak flow monitoring at home may increase the probability of predicting and hence, preventing,
impending asthma exacerbations (NIH, 1995). Importantly, consistently and validly measuring and
recording peak flow provides a quantitative record of lung function, which may be useful in letting
the patient know when to seek medical attention and letting the treatment team know the pattern
of lung functioning over time, in addition to having an additional index of patient compliance.
When more acute symptoms emerge and or when mild-to-moderate symptoms do not abate,
respiratory crises must be treated with quick relief or “rescue” medications (such as short-acting
inhaled beta2 agonists and oral steroids) and may require emergency medical intervention. Most
often, these medications are delivered through a MDI. Under special circumstances, anticholin-
ergics are prescribed for this purpose when the preferred medications are not well tolerated.
In order to facilitate adequate self-maintenance, per the NAEPP guidelines, patients should
establish with their primary medical provider an asthma action plan, which serves as a written
reminder of the patient’s management plan. An asthma action plan is a flowchart for patients and
their caregivers to determine what steps to take to best manage their asthma with particular symptom
presentations. For example, if the patient is experiencing symptoms suggesting that his or her
asthma is getting worse (e.g., activity restriction, waking at night due to coughing or wheezing), the
asthma action plan would indicate what pharmacological changes to make, including what medica-
tion(s) to take, dosage, and when to take the medication. If the symptoms persist or worsen, the
asthma action plan may indicate to take additional doses, add additional medications, or call
the doctor after having waited for a specified period of time after having dosed. Always included in
the asthma action plan are warning signs of an impending medical emergency to indicate to the
patient when he or she should go to the emergency department or call an ambulance.
Clearly communicating the information contained in the asthma action plan directly by health-
care providers to the patient helps obtain mutual agreement for the treatment plan. This, in turn,
enhances the likelihood of compliance on the part of the patient, who then has the same perceived
goals as the physician and understands the rationale for treatment, follow-up, and appropriate
alterations in the therapeutic plan. In addition, the patient will have a better understanding of the
need to recognize and avoid external and internal precipitants and the potential for medication-
induced adverse effects.
Obviously, self-monitoring is a key component of successful outpatient management of asthma,
yet it is often the missing link in the behavioral chain. It is recommended that persons with asthma
have three or four “well” outpatient visits per year to monitor progress and adjust medication and
behavior management plans. Between these visits, asthma patients must continually monitor and
treat their disease and have the assessment abilities to determine when they need additional contact
with medical professionals. Specifically, because of the intermittently emergent nature of asthma,
patients with the disease and people in their support system must be knowledgeable about the signs
and symptoms of an asthmatic emergency and what steps to take to terminate the episode quickly
or lessen the severity of the episode to provide a window of time in which to obtain professional
medical assistance. To establish this level of competence in their own care, asthma patients must
learn about the disease from their doctors and honestly report their levels of symptomatology and
compliance during regular visits.
Like patients with other chronic illnesses, asthma patients must take a greater-than-average
responsibility for their health and well-being and, in doing so, develop a strong working relationship
with their primary care treatment team. This type of relationship is necessary in the context of
asthma to provide patient compliance. When patients fail to obtain regular care for their disease out-
side of acute exacerbations, the probability of relapse is greatly increased. Understandably then, the
lack of an identified primary care physician and the inability or failure to obtain prescribed medica-
tions have been shown to be significantly related to short-term relapse (Emerman & Cydulka, 1998).
Finally, to understand the medical management of asthma, the emotional valence of coping
with asthma must not be overlooked. Asthma, particularly when first diagnosed, is a frightening
disease. Asthma is typically diagnosed after an acute episode of breathlessness, which is typically
not only terrifying to the patient, but also to others who witnessed the asthma attack or other
members of the patient’s support system who learn of the event later. Patients commonly have
the post hoc observation that they genuinely thought they were dying during their first moderate-
to- severe asthma attack. Unfortunately, it is under these less-than-ideal learning circumstances
that patients are given their first education about asthma, including being instructed on appropri-
ate medication administration. Given the relative complexity of self-management required of
asthma patients, at the very minimum patients should be provided upon diagnosis written
instructions regarding the proper use and administration of medications, the clinical rationale for
the various medications they will likely be prescribed, instructions on self-monitoring, signs and
symptoms to monitor that would indicate a need for additional medical attention on both outpa-
tient and emergency bases, and signs and symptoms that long-term therapies are decreasing in
effectiveness (NAEPP, 1997). Having such information in writing will enable the patient to review
and consult it, in addition to providing some education as to the patient’s support system, who
may not be present during the medical visit.
Behavioral Management of Asthma

As should be apparent to the reader at this point, successful asthma management cannot be defined
by medical intervention alone, but requires a great deal of behavioral management as well. Psycho-
logical factors must be addressed in asthma management, even when these factors do not amount
to a co-morbid, diagnosable, psychological disorder. Behavioral strategies may be employed both to
reduce the occurrence of asthma exacerbations and to help patients better manage acute episodes
when they occur. Many behavioral protocols have been developed to meet these targets, in accor-
dance with the NIH guidelines. Common elements of these protocols include educating patients on
their illness, improving compliance with maintenance and rescue medication regimens, compliance
with environmental management strategies, and management of psychological symptoms that may
contribute to the severity or duration of symptoms. Lehrer, Feldman, Giardino, Song, and Schmal-
ing (2002) suggest several biopsychosocial markers of successful behavioral intervention: quality-
of-life measures, reduction in medication usage, change in current status of asthma severity, and
the ability to regain normal flow volumes during an acute asthma exacerbation.
Several studies have examined the effectiveness of behavioral protocols for improving patient
knowledge and management of asthma (e.g., Hockemeyer & Smyth, 2002; Lucas et al., 2001).
Both individual as well as group protocols have been utilized and studied. Although the quality
of the data varies, generally speaking, these programs have been associated with improvements
in a number of outcome variables including knowledge of asthma, use of self-management
strategies, emergency department visits, asthma-related inpatient hospitalizations, physician
visits, medication compliance and reduction where appropriate, and number of asthma attacks
or exacerbations.
These findings suggest that the implementation of a behavioral intervention administered at the
time of diagnosis with supplemental interventions provided on an as-needed basis could prevent
unnecessary suffering and financial costs. In cases of poorly controlled asthma, management proto-
cols that include control of environmental asthma precipitants, enhanced medication regimens,
and smoking cessation have been shown to improve functioning (e.g., Irwin, Curley, & French,
1993). However, additional research is certainly warranted, as we do not yet have an empirically
supported protocol for behavioral management and we have not yet measured all the potentially
relevant outcome variables (such as medical cost offset).
There are two main roles that behavioral health-care providers can play in improving asthma
patient care: improving adherence to prescribed protocols when asthma is poorly managed and
treating co-morbid psychological and behavioral problems.
Improving Adherence and Compliance

Unfortunately, asthma treatment guidelines are not always implemented as suggested, and even
when they are, patients are not always compliant with treatment. In fact, patient compliance with
asthma treatment protocols is only around 50% (Center for the Advancement of Health, 2000). In
one study of asthma patients recently treated for exacerbations in the emergency department, 34%
had furry pets in their home, only 15% had mattress covers, hypoallergenic pillows, or covers, and
only 50% vacuumed their carpets weekly, all recommended management strategies (Emerman &
Cydulka, 1998). There are several possible reasons for lack of adherence and compliance at both the
patient and physician levels.
Physicians may not be aware that there is an empirically validated treatment protocol for the
diagnosis and treatment of asthma or may not know where to find the protocol materials. Alterna-
tively, they may know of the treatment guidelines but may not be familiar enough with them to
implement them effectively. They may not know (or may not be convinced) that adherence to the
guidelines is important for increasing the probability of patient compliance. It should also be noted
that physicians are typically operating under a number of different contingencies, including time
pressures and huge patient case loads; they may not feel they have the resources to implement the
guidelines as they ideally should.
Patients as well may fail to comply with their asthma treatment plan for a number of reasons.
They may not understand the rationale for the treatment protocol and therefore take it less
seriously than they should. They may not clearly understand what asthma is, what conditions may
exacerbate their symptoms, or how and when to use their medications. They may not know how to
identify asthma triggers or know what preventive steps they should take. They may be unmotivated
to make important lifestyle changes or lack the support necessary to do so. They may see managing
their asthma as a barrier to life satisfaction or unnecessary when they are not symptomatic. Patients
may also be reluctant to seek additional help when needed, or may not know that they need addi-
tional help in managing their asthma. Effective asthma management includes several complex
components and in order to increase the probability that the patient will comply with this kind of
comprehensive treatment, a system of care must be developed to provide prophylactic guidance in
asthma management as well as ongoing monitoring and intervention to collaborate with the patient
in managing his or her condition.
There are several signs of poorly managed asthma that may serve as a cue in primary care
settings to initiate a collaborative effort between a behavioral health-care provider, the patient, the
patient’s support system, and other members of the primary care team (NIH, 1995). Signs of poorly
controlled asthma include: nighttime exacerbations more than twice per week, increased or overuse
of “rescue” medications, underuse of maintenance medications, failure to achieve quick and
sustained relief when medications are administered during an acute episode, activity-induced
exacerbations, the use of over-the-counter respiratory medications, interference in activities of daily
living (attending and participating in work or school, regular physical activities, etc.), emergency
department visits, or hospitalizations related to an exacerbation (NIH, 1995).
If any of these symptoms should become apparent to any member of the health-care team, a
thorough functional analysis should be conducted by a behavioral health provider to determine
what antecedents interfere with the patient’s ability to follow his or her treatment plan. Then,
we can problem solve with patients about how to overcome barriers to adherence and develop
contingency management plans to improve their adherence through contingent reinforcement of
adherent behaviors.
Some strategies that may be applied at the antecedent level are obtaining verbal or written agree-
ment from the patient and key members of his or her support system to actively participate in
managing the disease. This may take the form of a self-contract. Another useful self-management
strategy is to establish precommitment by building asthma management tasks into the patient’s
daily routine.
At the level of consequences, patients should be encouraged to structure contingent reinforce-
ment for having complied with their treatment plan. Obviously, patients should receive praise
at medical visits when there is evidence that they have improved management of their asthma;
however, visits are too infrequent to provide a sufficient schedule of reinforcement to maintain
compliance for most patients. Initially patients should be encouraged to develop a plan for rein-
forcement to be delivered each time they perform a management task that has previously not been
complied with. For example, one patient who had been noncompliant with the medication planned
to eat a small piece of candy after he used his maintenance medication each day. Another patient
developed a token economy as a means of providing reinforcement for monitoring his symptoms,
taking his medication, and avoiding asthma triggers (e.g., vacuuming and changing his pillowcase
every day), a plan he found to be very successful. For some patients, involving their spouses or
other significant support persons in their contingency management plan may increase the likeli-
hood of compliance. Once compliance has reached acceptable levels, the schedule of reinforcement
can be thinned to best maintain the desired management behavior.
Finally, cultural beliefs or practices may be interfering with a patient’s ability to comply with his
or her treatment plan, and this requires special consideration. As described at the start of this chap-
ter, minority patients and particularly African American patients experience higher rates of
asthma-related death and exacerbations requiring emergent medical intervention (Blixen, Tilley,
Havstad, & Zoratti, 1997) than their Caucasian peers. Furthermore, one study suggests that African
Americans have less access to asthma specialists and are less likely to fill prescriptions for inhaled or
oral steroids (Zoratti et al., 1998). Unfortunately, the studies that examined the differential impact
of asthma on populations of color have been correlational and have not shed light on causal factors.
On an individual basis, however, behavioral health-care providers should attempt to understand
what sociocultural factors are impacting a patient’s ability to successfully manage his or her asthma.
Other Mental Health Services

In addition to improving adherence, behavioral health-care providers may offer a variety of other
services to asthma patients in the primary care or specialty mental health-care settings. If emotional
arousal triggers an attack, as is often the case, behavioral health-care providers could assist by
providing brief relaxation training. Skill training in the areas of communication and assertiveness
may also be helpful in assisting particular patients to learn how to communicate with health-care
providers and other people in the their lives who may be involved in their disease management. Fur-
thermore, more specialized treatments may be incorporated depending on patient need, including
smoking cessation and treatment of diagnosed psychological disorders.
Smoking Cessation. The prevalence of smoking and the importance of smoking cessation among
the asthmatic population must be given special consideration. Among different samples diagnosed
with asthma, 24–50% report a history of smoking and 15–43% report that they are currently smoking
(Bailey et al., 1990; Cline, Dodge, Lebowitz, & Burrows, 1994; Emerman & Cydulka, 1998). In addi-
tion, lifelong smoking has been associated with asthma mortality (Ulrik & Fredericksen, 1995).
Given these factors, when an asthma patient is also a smoker, he or she must be immediately
referred to a smoking cessation program for evaluation and treatment (see chapter 10 for more
detailed information on smoking cessation).
Treating Co-Morbid Psychological Disorders

As with other chronic illnesses, a patient’s psychological distress or disorders can jeopardize the
successful management of asthma. Specifically, anxiety, depression, and generalized psychological
distress have been demonstrated to have a significant impact on the course of the disease and, as
such, must be treated concurrently with the medical treatment of asthma. Although we will provide
an overview here, for a complete review of the relevant literature, Lehrer, Feldman, Giardino, Song,
and Schmaling’s (2002) “Psychological Aspects of Asthma” is recommended reading.
Anxiety and Asthma

There is a significant overlap between experiences of respiratory distress and anxiety. For example,
at the diagnostic level, in the general population it is estimated that between 2–4% of people will, at
some point in their lifetimes, develop panic disorder (Eaton, Kessler, Wittchen, & Magee, 1994).
However, among asthma patients, 6–30% are estimated to meet diagnostic criteria for panic
disorder (Carr, Lehrer, Rausch, & Hochron, 1994; Shavitt, Gentil, & Mandetta, 1992) and an addi-
tional estimated 13% are agoraphobic (Shavitt et al., 1992). At the symptom level, there are several
physical symptoms common to both anxiety disorders and asthma that patients may experience,
including dyspnea, or shortness of breath, accelerated heart rate, a sense of being smothered, feeling
lightheaded, a fear of dying during the acute event, a feeling of choking, sweating, and chest pain
(Smoller, Pollack, Otto, Rosenbaum, & Kradin, 1996). Because of the overlap in symptoms, differ-
ential diagnosis between asthma, anxiety (especially panic), or both is sometimes challenging and
must be skillfully undertaken (Smoller et al., 1996).
The data on asthma and anxiety raise a classic chicken-egg question: Which comes first, anxiety
or asthma? Simply, there is evidence supporting both sides. There is some evidence to suggest that
symptoms of panic (perhaps particularly hyperventilation) may quickly evolve into asthma attacks
(Lehrer, Isenberg, & Hochron, 1993). To the contrary, there is also evidence to suggest that patients
with preexisting asthma appear to have greater “anxiety sensitivity,” meaning that they may inter-
pret bodily sensations related to asthma (described above) as being more serious or dangerous than
they are in reality, although their pulmonary function may not be more compromised than other
patients (Carr, Lehrer, Rausch, & Hochron, 1994). Indeed, the fear of being breathless has been
shown to precipitate panic attacks in some asthma patients (Carr et al., 1992). The literature also
posits that there may be a bidirectional pathway between anxiety and asthma (see Lehrer, Feldman,
Giardino, Song, & Schmaling, 2002 for a review).
There have been several studies that suggest untreated anxiety in asthma patients may result in
decreased quality of life and increased health-care utilization. Among asthma patients with anxiety-
related symptoms or disorders, higher levels of use and sometimes overuse of asthma medications,
increased frequency and duration of hospitalizations due to asthma exacerbations, and higher levels
of mortality related to asthma have been observed (Mascia et al., 1989; Mawhinney et al., 1993; Van
der Shoot & Kaptein, 1990). For asthma patients with concurrent anxiety, treatment of both disor-
ders appears to be imperative, however, no empirical testing of concurrent treatment protocols have
yet been published. In lieu of an empirically established treatment, we recommend that existing
empirically validated treatments for anxiety be used (e.g., cognitive behavior therapy or CBT).
Depression and Asthma

Not only does anxiety figure significantly in the comprehensive treatment of asthma, but depres-
sion is also a prevalent co-morbid condition. In the case of depression, the research suggests that
coping with the challenges of living with the disease may give rise to depressive symptomatology
(Bell, Jasnoski, Kagan, & King, 1991). Some have hypothesized that when asthma patients choose to
assume a “sick role” and engage in behaviors symptomatic of learned helplessness that they are
more likely to subsequently become depressed (Chaney et al., 1999). In addition, the experience of
fatigue is common to both disorders, making a differential diagnosis important (Lehrer, Feldman,
Giardino, Song, & Schmaling, 2002).
Based on the limited available data on depression and asthma, it is recommended that integrated-
care clinicians carefully assess for concurrent depression in asthma patients, with a special emphasis
on evaluating the patient’s sense of control over the disease. Based on clinician assessment, several
treatment strategies may be appropriate, although none have been empirically validated. First,
additional psychoeducation may be necessary to help patients learn active coping strategies for
managing their asthma symptoms. Second, clinicians should carefully assess for the presence of
secondary-gain issues. In particular, if the patient’s observed limitations (activities, etc.) exceed his
or her known level of disability, the clinician would be well advised to assess for a pattern of nega-
tive reinforcement, that is, is the patient experiencing a removal of aversive stimuli based on his or
her behavior? For example, a patient may be unable to participate in carrying a full laundry basket
to a downstairs laundry room because of the high probability of breathlessness on exertion.
However, the patient may then assert that she is unable to load the laundry into the washing
machine, a task she finds undesirable, due to her asthma, although appropriate accommodations in
completing this task may be available. Thus, the patient is no longer responsible for laundering
clothing, although she may be physically able to complete at least some of the tasks involved.
Stress and Asthma

Among asthma patients and their treatment providers, there appears to be a commonsense under-
standing that psychological stress may precede asthma exacerbations. Research has only begun to
investigate and understand the potential relationship between asthma and stress; however, several
studies have suggested a significant causal relationship (Busse et al., 1995). Several correlational
studies have shown that asthma patients have heightened bronchoconstriction in response to stress
than nonasthma patients (e.g., Ritz, Steptoe, DeWilde, & Costa, 2000). There is some additional
evidence to suggest that this pattern of physiological responding may be related to a passive style of
coping with stressful situations (cf. review by Isenberg, Lehrer, & Hochron, 1992).
Two primary questions remain to be answered by the research literature with regard to the rela-
tionship between stress and asthma. The first question relates the role of operant conditioning in
the relationship between stress and asthma attacks. Second, the potential treatment benefits of
teaching stress management strategies or assertiveness skills to persons who suffer from stress-
related exacerbations are unknown.
Although the research is not yet developed sufficiently to answer these questions, it is our
recommendation that integrated-care practitioners conduct a functional analysis of asthma exacer-
bations occurring in the context of a stressful situation. In addition, because there are no empirically
based treatment recommendations for stress-related asthma, we recommend that the integrated-
care clinician use theoretically sound treatment strategies for stress management and improving
active coping.
How Much Can We Do?: A Stepped-Care Model of Asthma Management

Several researchers have suggested a stepped-care model for the management of chronic illness
that details optimal roles and responsibilities for health-care professionals to improve patient
adherence and outcomes that take into account the severity of illness (Glasgow, 1995; Katon, Von
Korff, Lin, & Simon, 2001; Von Korff & Tiemens, 2000). Several studies have demonstrated that
the use of “care extenders,” meaning health professionals other than physicians such as nurses,
nurse practitioners, social workers, and psychologists, to provide auxiliary services improves the
process and outcome of health care related to asthma (Bailey, Kohler, & Richards, 1999; Winsor,
Bailey, & Richards, 1990).
Applying a stepped-care model to the management of asthma, the following steps are recommended.
Level 1: Prevention, Diagnosis, Outcome Monitoring, Patient Education
• The patient is diagnosed with asthma, ideally by the primary care physician or, in cases of
acute respiratory crisis, by emergency department physicians. The physician may initiate
treatment at this time if the complexity of the case is within his or her scope of practice or
immediately refer to a specialist if indicated.
• After the diagnosis is made, the patient is prescribed medications and is given some brief
education from his or her primary care physician or a care extender during that initial
visit. Condensed information should be provided regarding the disease itself, the impor-
tance of compliance, and modifications to make to the patient’s environment to reduce
exposure to allergens.
• Asthma action plans are developed for each patient to provide individualized instructions
for short-term management of exacerbations and long-term management of the disease.
• All newly diagnosed asthma patients are invited to attend weekly, behaviorally based,
informational series held in a group format on the management of their disease. Ideally,
groups should be held in the familiar primary care setting and lead by a behavioral health-
care provider or other care extender.
• Patients should be monitored by the primary care team for adherence to and compliance
with medication and behavioral regimens.
The following handouts should be included as educational components of this group

(NAEPP, 1997):
1. “What everyone should know about asthma control”

2. “How to use your metered-dose inhaler the right way”
3. “How to use your peak flow meter”
4. “How to control things that make your asthma worse”
5. “Patient self-assessment form for environmental and other factors that can make asthma
worse”
Level 2: Active Treatment in Primary Care
• Patients may be identified as failing to comply with their prescribed treatment. The
decision regarding when a patient is not complying with treatment can be made by a
number of professionals including his or her primary care physician, care extenders such
as nurses, pharmacist, ER staff, the patient him- or herself or a family member, or his or
her managed care company if utilization does not correspond with illness severity.
• Behavioral health-care providers (with the support of the primary care team) conduct a
functional analysis of noncompliance and actively problem solve with patients about how
to improve self-management.
• Minimal supplemental education outside of Level 1 group may be provided within the
context of primary care visits (e.g., patient does not adequately understand when to use
crisis inhaler and requires more instruction).
Level 3: Specialty Care Within the Primary Care Setting

• If determined that additional behavioral factors may be interfering with management, such
as co-morbid psychological diagnoses or smoking, involve colocated behavioral health-
care providers in the primary care visit to provide supplemental education or treatment.
Level 4: Referral to Specialty Care Setting
• For patients who have poorer outcomes at lower levels of disease severity, are chronically
noncompliant, or have more complex clinical presentations, refer to treatment providers
in the community who specialize in the management of asthma and pulmonary disease,
including specialty mental health-care providers such as psychologists and psychiatrists.
• At this level, the specialist and the primary care team must decide to establish a collabora-
tive relationship to provide for the continued management of the patient’s needs.
Figure 19.1 exemplifies a decision tree for the suggested stepped-care model.
Potential for Medical Cost Offset

At the time of this writing, we know of no studies directly measuring medical cost offset as an out-
come of successful asthma management. However, managing patients with optimum effectiveness
and efficiency has clearly been articulated as a main goal of disease management. Unfortunately,
cost outcomes are rarely reported in the clinical outcome literature. In one published study,
researchers developed a seven-session (90 minutes each), group self-management intervention that
featured self-monitoring of peak flow rates and managing exacerbations (Kotses et al., 1995; Kotses,
Stout, & McConnaughy, 1996). The program cost approximately $200 per patient to implement,
but savings in direct and indirect asthma-related bills the following year per patient averaged $500.
These savings were attributed primarily to a reduced number of absences from work and
hospitalizations. If the medical cost offset observed in this program is generalizable, it may be
hypothesized that more effectively managing asthma across settings could result in not only
improved patient care, but economic benefit for health-care systems and third-party payers as well.
Summary
In this chapter we have provided a primer for behavioral health providers in caring for asthma
patients both in primary (integrated) as well as specialty mental health-care settings. Although the
ASTHMA MANAGEMENT DECISION TREE

Patient diagnosed with asthma by MD
Medications prescribed/brief education provided by MD during same visit
More extensive education provided in group format
Adherence and compliance monitored
Complies Does not comply
Specialty care within primary care setting
Complies Does not comply
Specialty care provided outside of primary care setting

Fig. 19.1 Decision tree for stepped-care model.
complexities of and barriers to participating as a member of an asthma treatment team are numerous,
it is our belief that, given the existing data, behavioral health-care providers could provide much-
needed services to patients and their families, ultimately resulting in improved health and quality of
life for our patients.
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RT9467_Index.fm Page 383 Tuesday, November 16, 2004 11:32 AM
Index
A Alcohol abuse
prevalence of, 144
Abstinence model, 150–151 and suicide, 115
Acceptance, 339 Alexithymia, 161–163
Acceptance/Avoidance Diabetes Questionnaire, 339 American Biodyne, 166–167
Action stage (obesity), 260 American College of Sports Medicine, 263
Activity/lifestyle management, 246 Amotivational syndrome, 149
Acute pain, 316 Amphetamines, 145
Acute stress disorder, 135–136 Antisocial personality disorder, 114
Adherence to medications, 348 Anxiety disorders, 87–90
in asthma treatment, 373–374 assessment of, 90–98
biological indicators, 354 and asthma, 375–376
clinical setting factors, 350, 362 case example, 103–104
and depression, 363–364 co-morbidity of, 89
disease factors, 350, 359–360 diagnostic tools, 95–98
factors, 348–350 economic cost of, 89
follow-up and maintenance, 363 generalized anxiety disorder (GAD), 94
interventions for, 350–351 medical conditions, 88
measurement of, 351–354 medical cost offset, 89
Medication Event Monitoring System (MEMS) panic attacks, 93–94
caps, 354 percentage of problems in primary care, 6, 87
medication regimen factors, 349, 358–359, 363 prevalence rates of, 87
patient factors, 349, 360–362 prevention of, 102–103
patient-provider relationship factors, 349, 362 self-report instruments, 96
pill counts, 354 severity of, 95
planning sheets, 357 somatic symptoms of, 91
Prescriptive Adherence and Education (PACE) treatment of, 54, 98–102
intervention, 355–364 worry in, 94
in primary care, 364–365 Anxiety in surgery, 280–281
self-reporting of, 351–353 Anxiety Sensitivity Index, 96
slips in, 363 Asthma, 367–368
social support in, 359 and anxiety, 375–376
strategies for, 352–353 behavioral management of, 372–375
and substance abuse, 363 classification of, 369
Adolescents, suicidal behavior in, 114 co-morbidity psychological disorders, 375
Advice rule, 164 and depression, 376
African Americans, obesity in, 253 diagnosis of, 368–369
Aftercare, 154 economic costs of, 368
Agency for Health Care Policy and Research (AHCPR), 60 medical management of, 370–372
Agoraphobia, 93 overall death rate, 368
Albany Panic and Phobia Questionnaire, 96 personal and societal impact of, 367
383
384 • Index
prevalence of, 367 pathway, 12

and stress, 376–377 therapist-guided vs. patient-guided change, 28–29
Asthma treatment, 369–370 Behavior modification, 185–190
adherence and compliance, 373–374 child intervention, 189
decision tree for, 379f classroom-based, 189–190
medical cost offset in, 378 parent training, 187–189
mental health services in, 374–375 Benign exertional headache, 308
peak flow analysis in, 371 Benzodiazepines, 146
self-monitoring in, 371 Best-practices video training sessions, 24
smoking cessation in, 375 Biochemical markers, 209–210
stepped-care management model, 377–378 Biodyne Centers, 163
Attention deficit/hyperactivity disorder (ADHD), 177–178 Bioelectrical impedance, 256–257
assessment and diagnosis of, 182–185 Biofeedback, 303–304
behavior modification, 185–188 Biological indicators, 354
combined behavioral and pharmacological treatment Biological therapy, 238
of, 190–192 Bipolar disorder, 113
costs of services for, 192–193 Blackouts, 156–157
evidence-treatments for, 179 Blame game, 158
medication treatment guidelines, 191 Body mass index (BMI), 257; see also Obesity
monitoring, 193–194 chart of, 258f
pharmacological treatment of, 180–182 classification of obesity with, 258
prevention of, 192 and health-care costs, 254
primary care service for, 179–180, 194 and mortality, 255f
rating scales, 183–185 in obesity treatment, 266–267
Automobile accidents, 148 Borderline personality disorder (BPD), 114–115
Axioms, 155 Breast cancer, 237
Axis II personality disorder, 114 Brief Diabetes Knowledge Scale, 340
Bupropion SR, 204–205
B
C
Barriers to HARRT Adherence Questionnaire
(BHAQ), 356 Cancer, 237
Beck Anxiety Inventory, 341 assessment of, 239–244
Beck Anxiety Inventory for Primary Care biopsychosocial aspects of, 238–239
(BAI-PC), 96 gender differences in, 237
Beck Depression Inventory (BDI), 79–80, 320, 340–341 interventions, 242–244
Beck Depression Inventory for Primary Care metastasis, 237
(BDI-PC), 259 and smoking, 202–203
Behavioral health care, 15–16 treatment of, 237–238
integration with primary care, 16–18 Cancer Care Monitor, 242
segregated model of, 16–17 Cancer patients
Behavioral health care providers, 3 functioning and quality of life, 241–242
clinical practice skills, 32–36 mental health assessment, 240–241
consultation skills, 39–43 psychosocial interventions for, 244–245
cotraining with primary care providers, 47–48 structured interventions for, 245–247
documentation and feedback skills, 45 Cancer Rehabilitation Evaluation System (CARES),
graduate training of, 48–49 242
integrated training programs, 23 Cardiovascular disorders, 88
practice-based core competencies training, 31–32 and diabetes, 330
practice management skills, 36–39 and obesity, 255
role differentiation, 49–50 and smoking, 202–203
team performance skills, 43–45 Catastrophizing, 112, 318–319
therapeutic vs. team relationship, 30 Center for Epidemiologic Studies Depression Scale
traditional vs. functional assessment models, 29–30 (CES-D), 259
Behavioral medicine, 4–5 Central nervous system (CNS) depressants, 146, 150
Behavioral model (substance abuse treatment), 150 Central nervous system (CNS) stimulants, 180–182
Behavior change, 23–24 Chemotherapy, 238
cure vs. strategic change, 26–28 Child Behavior Study (CBS), 179
medical illness vs. stress-coping models, 24–26 Child intervention, 187–189
Index • 385
Children prevention of, 192

attention deficit/hyperactivity disorder (ADHD) in, primary care service for, 179–180
177–178 rating scales, 183–185
headaches in, 307 Consider rule, 164
obesity in, 253–254 Consultation-liaison (C-L) psychiatry, 5
psychological treatments for, 55 Consultation skills, 33–34, 39–43
Chronic condition programs, 21 Consumer-centered care, 17
Chronic diseases, treatment of, 6–7 Contemplators (obesity), 260
Chronic low back pain (CLBP), 315–317 Contingency management, 55
Chronic pain, 293 Coping, 318–319
vs. acute pain, 316 in diabetes treatment, 334–335
assessment of, 320–322 Coping style, 281, 283
catastrophizing, 318–319 Core-competencies training, 31–32
coping with, 318–319 clinical practice skills, 32–36
costs of, 315 consultation skills, 39–43
and depression, 316–317 documentation skills, 45
gate control theory, 315–316 feedback skills, 45
interdisciplinary treatment members, 323 practice management skills, 36–39
and occupational functioning, 319–320 team performance skills, 43–45
prevention of, 325 Counseling interventions, 59
psychopathology of, 316–318 Crack cocaine, 145
psychosocial factors, 316–320 Critical incident stress debriefing (CISD), 135
and suicide, 112 Critical pathways, 21
symptoms of, 315 Curbside consultations, 41, 57
treatment of, 322–324
Cigarette smoking, see Smoking
Classroom-based behavior modification, 189–190 D
Clinical assessment, traditional vs. functional models, 29–30
Clinical case vignettes, 24 Daily report card (DRC), 190, 193–194
Clinical depression, see Depression Dallas Back Pain Questionnaire (DBPQ), 320–321
Clinical practice skills, 32–36 Depressants, 146
Clinician Administered PTSD (CAPS), 134–135 Depression, 73–74
Clonidine, 204–205 and adherence to medications, 363–364
Cluster headache, 306 assessment of, 78–81
Cocaine abuse, 145 and asthma, 376
Codeine, 146 cognitive behavior therapy for, 76–77
Cognitive-behavioral therapy (CBT), 54–55 and diabetes, 331, 340–341
for anxiety disorders, 99–100 economic analysis of, 81
assessment of patient outcome in, 83 and fertility, 223–224
for depression, 76–77 group psychotherapy, 82
for headaches, 304 and headaches, 308
for infertility clients, 228–230 long-term management of, 78
main areas of intervention, 77 and pain, 316–317
for posttraumatic stress disorder, 136 percentage of problems in primary care, 6
psychoeducation in, 99–100 primary prevention of, 78
quality assurance in, 83 psychomotor retardation in, 78
Cognitive restructuring, 262 psychosocial treatments for, 74–78
Cognitive therapy, 246 and somatization, 167
Collaborative care, 89–90 stress-coping analysis, 25–26
Colocated specialty model, 21–23 and suicide, 112–113
Communication skills, 246 symptoms of, 78
Compensation, 319–320 treatment costs, 81–83
Conduct disorder (CD), 177; see also Attention deficit/ Depression Anxiety Stress Scales, 96
hyperactivity disorder (ADHD) Dexantrin, 265
assessment and diagnosis of, 182–185 Diabetes, 329–330
behavior modification, 185–188 and alcohol consumption, 337
costs of services for, 192–193 biopsychosocial aspects of, 329
evidence-treatments for, 179 dietary factors, 335–337
medication treatment guidelines, 191 economic cost of, 331–332
monitoring, 193–194 medical management of, 330–331
386 • Index
prevention of, 342–343 Elderly population and suicide, 114–115

psychological complications, 331 Electromyography (EMG), 304
risk factors, 342 Electronic databases, 60
self-management of, 330–331 Emotional assessment, 259
types of, 329–330 Emotion dysregulation, 120–121
Diabetes Care Profile, 340 Empirically supported treatments (ESTs), 54
Diabetes Control and Complications Trial (DCCT), 330–331 evidence-based medicine, 59–61
Diabetes Knowledge Scale, 340 for infertility, 230–231
Diabetes Self-Management Profile, 340 in mental health, 64
Diabetes treatment, 332–338 patient-centered care approach in, 65–66
acceptance of, 339 patient education model, 67
areas of intervention, 332 patients of, 63–65
assessment of variables in, 339–341 population diversity planning in, 65
avoidance of, 339 primary behavioral health model, 61–63
coping skills in, 334–335 in primary care, 63–69
dietary factors, 340 primary care service philosophy in, 63
diet in, 335–337 relapse prevention in, 67–68
economic analysis of, 341–342 service delivery formats, 66
economic cost of, 341 surgical preparation as, 274–275
education, 333–334 team-based intervention in, 68–69
exercise program in, 337–338 treatment length and intensity, 66–67
health-care providers for, 339 Endocrine disorders, 88
knowledge assessments in, 340 Epidemiological Catchment Areas (ECA) Study, 87
medical cost offset, 341–342 Evidence-based medicine, 59–61, 179
medical variables in, 340 Exchange Lists for Meal Planning, 263
patient adherence and motivation in, 338–339 Exercise, 337–338
physician collaboration in, 342 Exposure, 100–101
psychosocial factors, 340–341 Extended practice consultation, 24
social support in, 335
stress management in, 334–335
Take Charge! protocol, 332–333 F
Diabetes Treatment Satisfaction Questionnaire, 341
Dialectical behavior therapy (DBT), 111, 124 Family systems health-care model, 22
Didactic training, 24 Family therapy, 55
Diet Fastin, 265
in diabetes treatment, 335–337 Fatigue, 239
in obesity treatment, 263 Feedback skills, 45
Dietary fat, 309 Feeling game, 158
Diet/eating patterns assessment, 258–259 Fertility Adjustment Scale (FAS), 226
Diethylpropion, 265 Fertility Problem Inventory (FPI), 226
Disease management, 13 File card game, 158
Disruptive behavior disorders (DBDs), 177 Fluoxetine, 82
Distressing Event Questionnaire (DEQ), 134–135 Fluvoxamine, 82
Documentation skills, 34, 45 Food Guide Pyramid, 263
Donor insemination, 227 Functional assessment models, 29–30
Drug abuse and suicide, 115 Functional Assessment of Cancer Therapy-General
DSM-IV disorders, 25 (FACT-G), 242
diagnosis of, 92 Functional Living Index-Cancer (FLIC), 242
treatment of, 5
Dual x-ray absorptiometry, 256
Dyadic Adjustment Scale (DAS), 225–226 G
Dysthymia, see Depression
Gastric partitioning, 266
Gate control theory of pain, 315–316
E General consultation services, 20–21
Generalized anxiety disorder (GAD), 88
Eating patterns assessment, 258–259 diagnosis of, 93, 94
Elderly population symptoms of, 91
substance abuse in, 147 General Well-Being Schedule, 259
and suicide, 111–112 Goal setting, 246
Index • 387
Graduate training, 48–49 empirically supported treatments (ESTs),

Group psychotherapy, 82 230–231
Group therapy, 153–154 high incidence of, 221–222
impact on couples, 224
long-term management of, 231–232
H medical cost offset, 233–234
medical treatment of, 227
Hamilton Rating Scale of Depression (HRSD), 320 psychoeducation, 227
Hawaii Medicaid Study, 10, 163, 171–172 psychological aspects of, 222–224
Hawaii Project, 144 psychological interventions, 227–230
Headaches, 293 social factors of, 224–225
assessment and diagnosis of, 298–300 social stigma and isolation, 224–225
benign exertional, 308 and stress, 223
biopsychosocial aspects of, 294 support groups, 228
cluster, 306 treatment compliance, 231
dietary factors, 309 Infertility Questionnaire (IFQ), 226
epidemiology of, 294–295 Information and decision-support pathway, 11
gender differences in, 294–295 Inpatient care, 151–152
index, 302 Inpatient hospitalization, 118–119
migraine, 294–295 Insight game, 158
monitoring, 300–303 Integrated care, 2
nonpharmacological, 305–306 advantages of, 5–10
prevention of, 307–308 aims of, 2–3
prodrome, 294–295 vs. behavioral medicine, 4–5
psychological testing of, 303 vs. consultation-liaison psychiatry, 5
tension, 294–295 consumer-centered care in, 17
Headache treatment continuum of, 3f
biofeedback training, 303–304 economic drivers of, 17–18
cognitive behavior therapy, 304 evidence for, 13
cost effectiveness of, 307 implementation of, 10–12
nonpharmacological, 301–302 major drivers of, 16–20
in primary care, 295–298, 304–305 medical cost offset in, 7–10
relaxation therapy, 304–305 priority areas in, 11
Healing imagery, 247 problems targeted in, 4
Health care crisis, 1, 15 vs. segregated model of mental health care,
Health-care team (HCT) model, 19–20 16–17
Health Plan Employee Data Information Set (HEDIS), 210 services in, 6
Health plans, 15–16 of somatization, 174
Heroin addiction, 144–145 treatment of physical problems in, 6–7
Highly active antiretroviral therapy (HAART), 348 Intensive outpatient program (IOP), 152–153
Horizontal integration programs, 61–62 Interdisciplinary pain management, 322–324
Hormone therapy, 238 Interoceptive exposure, 101
Hospitalization and suicide, 118–119 Interventions, 54–55
Hydrodensitometry, 256 child-focused, 187–189
Hypochondria, 162 school-based, 187
for surgical preparation, 279
team-based, 68–69
I Interventive assessment, 119–120, 122–123
Ionamin, 265
Imaging techniques, 257 Irritable bowel syndrome, 88
Immunotherapy, 238
Individuals with Disabilities Education Act (IDEA), 183
Infertility, 221–222 J
assessment of, 225–227
biological and medical aspects of, 222 Job satisfaction, 319–320
biopsychosocial theory of, 222
causes of, 222
cognitive behavior therapy for, 228–230 K
collaboration between mental health professionals and
physicians, 232–233 Kaiser Permanente, 161–163, 170–171
388 • Index
L MMPI-2 personality assessment test, 303

Mood disorders, 94
Learned helplessness, 169–170 Multidimensional Pain Inventory (MPI), 318, 321
Lifestyle management, 246 Musical chairs game, 158
Likert scale, 356
Litigation and pain, 317
Low-fat diet, 309 N
Lung diseases, 202
Nasal sprays, 203–204
National Ambulatory Medical Care Survey
M (NAMCS), 179
National Asthma Education and Prevention Program, 369
Magellan Health Services, 2 National Committee for Quality Assurance (NCQA),
Maintenance stage (obesity), 260 201–202
Managed care organizations (MCOs), 213–215 National Comorbidity Study (NCS), 87
Marijuana abuse, prevalence of, 144 National Institute of Mental Health (NIMH), 162
Marital therapy, 55 National Institute on Alcoholism and Alcohol Abuse,
Maudsley Obsessive-Compulsive Inventory, 96 144–145
Mazindol, 265 National Institute on Drug Abuse (NIDA), 144–145
M.D. Anderson Symptom Inventory (MDASI), 242 National Vietnam Veterans Readjustment Study (NVVRS),
MEDFICTS Dietary Assessment Questionnaire, 258 131
Medical cost offset, 7–10 Neurological disorders, 88
in diabetes treatment, 341–342 Neuromental Questionnaire (NMQ), 165
in infertility treatment, 233–234 Nicoderm, 203
and somatization, 164 Nicorette, 203
Medical disability case managers, 323 Nicotine replacement therapy (NCT), 203–204
Medical history, 281 Nicotrol, 203
Medical illness, 24–25, 112 Nonadherence to medications, 348; see also Adherence to
Medical model (substance abuse treatment), 150 medications
Medical offices, 284 clinical setting factors, 350
Medical utilization, 7–9 disease factors, 350
of panic disorder (PD) patients, 88 factors, 348–350
Medication Event Monitoring System (MEMS) caps, 354 health and financial consequences of, 348
Mental health care medication regimen factors, 349
empirically supported treatments (ESTs), 64 patient factors, 349
expenditures, 1 patient-provider relationship factors, 349
segregated model of, 16–18 Nonnicotine medications, 204–205
therapist-guided vs. patient-guided, 28–29 Noradrenaline, 264–265
training implications, 20 Noradrenergic drugs, 264
Mental health professionals (MHPs), 232–233 Nortriptyline, 204–205
collaboration with health care providers, 296–298 Nurses, 323
collaboration with physicians, 75–76
relationship with primary care providers, 295–296
Mentoring, 24 O
Meridia, 264–265
Metabolic disorders, 88 Obesity, 253
Metamphetamines, 145 assessment of, 256–260
Metastasis, 237 assessment tools, 256–257
Metered-dose inhaler (MDI), 370–371 classification of, 258
Methadone, 146 co-morbidities of, 255–256
Mexican Americans, obesity in, 253 costs of, 254
Michigan Alcoholism Screening Test, 147 diet/eating patterns assessment, 258–259
Migraine, 294–295; see also Headaches emotional assessment, 259
dietary factors, 309 etiology of, 254–255
prevention of, 307–308 health risk assessment, 257
responses to nonpharmacological treatment, 305 health risks of, 255–256
Mind/Body Program for Infertility, 228–229 in minority population, 253
Mini-International Neuropsychiatric Interview (MINI), 97 pharmacotherapy treatments, 264–266
Minnesota Multiphasic Personality Inventory (MMPI), physical activity assessment, 259
317, 320 prevalence of, 253–254
Index • 389
prevention of, 267 Paranoia, 149

psychosocial treatments, 260–263 Parasuicide, 115–116
stages of change assessment, 260 Parent training, 187, 188–189
Obesity treatment, 260–268 Patient-guided change, 28–29
algorithm, 267f Patients, 53–54
behavioral interventions in, 262–263 acceptance of treatments, 339
cognitive restructuring in, 262 adherence to treatment, 338–339
diet in, 263 avoidance of treatments, 339
goals in, 261 compliance rates, 77
guidelines, 266–267 education of, 67
noradrenergic drugs in, 264 emotional arousal of, 120–121
physical activity in, 263 of empirically supported treatments (ESTs), 63–65
psychosocial interventions, 260–263 motivation, 338–339
relapse prevention in, 262 population diversity, 65
self-monitoring in, 261 Peak flow, 371
serotonin and noradrenaline reuptake inhibition, Penn State Worry Questionnaire, 96
264–265 Pharmacotherapy, 63
social support in, 262 vs. psychosocial intervention, 82
stimulus control in, 261–262 Phendimetrazine, 265
stress management in, 262 Phentermine, 265
surgery in, 266 Phentermine resin, 265
Obsessive-compulsive disorder, diagnosis of, 93 Phenylpropanolamine, 265
Occupational therapists, 323 Phobias
Oocyte donation, 227 in children, 55
Oppositional deficit disorder (ODD), 177–178; see also diagnosis of, 93
Attention deficit/hyperactivity disorder (ADHD) treatment of, 55
assessment and diagnosis of, 182–185 Phonophobia, 294–295
behavior modification, 185–188 Photophobia, 294–295
costs of services for, 192–193 Physical activity
evidence-treatments for, 179 assessment of, 259
medication treatment guidelines, 191 in obesity treatment, 263
monitoring, 193–194 Physical problems, treatment of, 6–7
prevention of, 192 Physical therapists, 323
primary care service for, 179–180, 194 Physicians, 53
rating scales, 183–185 collaboration with mental health professionals, 75–76
Orlistat, 265–266 databases for, 60
Outpatient care, 151–152 in primary care settings, 55–56
as pushers, 146–147
role in pain treatment, 323
P Physiological biofeedback, 303
Pill counts, 354
Pain, 315 Plegine, 265
assessment of, 320–322 Population-based care, 58–59
catastrophizing, 318–319 development of, 58
coping with, 318–319 goals of, 18–19
costs of, 315 for posttraumatic stress disorder, 133
and depression, 316–317 Posttraumatic Diagnostic Scale, 96
gate control theory, 315–316 Posttraumatic stress disorder, 129–130
interdisciplinary treatment of, 322–324 acute stress disorder, 135–136
and job satisfaction, 319–320 assessment of, 133–134
and occupational functioning, 319–320 cognitive- behavioral treatment for, 136
prevention of, 325 co-morbidity of, 131–132
psychopathology of, 316–318 critical pathways, 130
psychosocial factors, 316–320 diagnosis of, 93
Panic attacks, 91, 93–94 gender differences in, 131
Panic disorder (PD), 88–89 integrated primary care service for, 137–139
context of, 93–94 and physical health, 132–133
diagnosis of, 93 population-based care for, 133
percentage of problems in primary care, 6 prevalence rates of trauma exposure, 130–132
symptoms of, 91 psychosocial treatments for, 137
390 • Index
screening of, 134–135 Primary Care Evaluation of Mental Health Disorders

and suicide, 114 (PRIME-MD), 97
symptoms of, 129–130 Primary care integration
Practice management skills, 33, 36–39 colocated specialty model, 21–23
Preaddictive group, 155 consumer-centered care in, 17
Precontemplators (obesity), 260 economic drivers of, 17–18
Preparation stage (obesity), 260 horizontal integration programs, 61–62
Prescription drugs, abuse of, 146–147, 321–322 models of, 20–23
Prescriptive Adherence and Education (PACE) for posttraumatic stress disorder, 137–139
intervention, 355 primary behavioral health model, 20–21
adherence planning sheets, 357 vs. segregated model of mental health care, 16–17
adherence-related lifestyle, resources and skills, Primary care physicians (PCPs), 164–166
360–362 Primary care providers, 53
adherence to regimen, 358 clinical practice skills, 32–36
appropriateness of regime, 359 collaboration with mental health professionals,
Barriers to HARRT Adherence Questionnaire 296–298
(BHAQ), 356 consultation skills, 39–43
clinical barriers, 363 cotraining with behavioral health providers, 47–48
depression, 363–364 documentation and feedback skills, 45
disease beliefs and treatment, 359–360 integrated training programs, 23–29
follow-up and maintenance, 364 practice-based core competencies training, 31–32
intervention guidelines, 356–357 practice management skills, 36–39
knowledge of regimen, 358 relationship with mental health professionals, 295–296
missing doses, 363 team performance skills, 43–45
patient-provider relationship, 362 Primary Care PTSD (PC-PTSD), 134–135
responses to slips in adherence, 363 Primary infertility, 221
social support in, 359 Problem solving, 246
and substance abuse, 364 Prodrome, 294–295
Presurgical preparation form, 286 Progressive muscle relaxation (PMR), 245
Primary behavioral health model, 61 Prozac, 82
chronic condition programs in, 21 PSTD Checklist, 96
cotraining in, 47–48 Psychological problems, 74–75
dissemination of, 45–48 Psychologists, role in pain treatment, 323
general consultation services in, 20–21 Psychosocial Adjustment of Illness Scale (PAIS), 241
horizontal integration in, 61–62 Psychosocial treatments, 74–75
role of mentor-trainer in, 46–47 for cancer patients, 244–245
training implications, 21 compliance, 77–78
vertical integration programs, 62–63 for obesity, 260–263
Primary care, 3 vs. pharmacotherapy, 82
adherence to medications in, 364–365 physician collaboration in, 75–76
in behavioral health-care services, 6 for posttraumatic stress disorder, 137
collaborative care in, 89–90 in smoking cessation, 205–207
common mental disorders in, 56 Psychotherapy, 63
definition of, 278 Pulmonary disorders, 202
diagnosis and treatment in, 57 Pushers, 145–147
diversity in, 56
empirically supported treatments (ESTs) in, 53–55,
63–69 Q
goals, 64
for headaches, 295–298, 304–305 Quality of life, 241
integration with behavioral health care, 16–18 Quick PsychoDiagnostics Panel (QPD), 98
medical orientation in, 56–57
patients of, 19
population-based, 18–19, 58–59 R
psychosocial factors in, 57
setting, 55–58 Radiotherapy, 237
smoking cessation in, 207–212 Randomized clinical trials (RCTs), 55
vs. specialty care, 3 Rate Your Plate dietary assessment questionnaire, 258
and surgery, 277–279 Relapse prevention, 67–68, 262
treatment of behavior disorders in, 179–180 Relaxation therapy, 304–305
Index • 391
Relaxation training, 246 Hawaii Medicaid project, 171–172

Rescue game, 158 historical perspective, 161–163
Respiratory disorders, 88 integrated behavioral care, 174
Rubber yardstick game, 158 and learned helplessness, 169–170
medical confidentiality, 173–174
medical cost offset, 164
S outreach methods, 164–166
percentage of problems in primary care, 6
Sanorex, 265 and self-efficacy, 169–170
Schizophrenia, 113–114 treatment protocol, 168–170
Seattle Group Health Cooperative (GHC), 212 Special person game, 158
Secondary infertility, 221 Specialty care, 3
Self-efficacy, 169–170, 279–280 Specific phobia, diagnosis of, 93
Self-help interventions, 205–206 Spinal disorders, 315
Self-hypnosis, 55 Spousal battery, 149
Self-monitoring, 261 State-Trait Anxiety Inventory, 259
Serotonin, 264–265 State-Trait Anxiety Inventory (STAI), 225
Sertraline, 83 Stimulant therapy, 180–182
Sexual trauma, 131 Stress-coping models, 25–26
Sibutramine, 264–265 Stress management, 11–12
Sickness Impact Profile, 241 in asthma treatment, 376–377
Situational exposure, 100–101 in brief structured interventions, 246
Skin caliper, 256 in diabetes treatment, 334–335
Skin-fold measurements, 256 in obesity treatment, 262
Smoking, 201 Structured Clinical Interview for DSM-IV-Non Patient
biochemical markers, 209–210 Version (SCID-NP), 320
environmental and psychosocial variables, 208–209 Structured interventions, 245–247
health risks, 202–203 Substance abuse, 145
history of, 208 and adherence to medications, 364
integrated treatment models, 210–212 assessment of, 147–150
nicotine dependence, 208 blame game, 158
nicotine replacement therapy, 203–204 effects on medical treatment, 143–144
and pregnancy, 203 feeling game, 158
public policy, 216–217 file card game, 158
status of, 207–208 insight game, 158
Smoking cessation, 201–202 intensive outpatient program (IOP), 152–153
and asthma, 375 medical costs of, 143–144
implementation of, 213–215, 215–216 musical chairs game, 158
nonnicotine therapies, 204–205 prevalence rates of, 144–145
organizational systems/systems changes, 212 pushers, 145–147
patients’ readiness to change in, 209 rescue game, 158
pharmacological interventions in, 203–205 rubber yardstick game, 158
in primary care, 207–212 signposts, 148–149
psychosocial treatments for, 205–207 special person game, 158
self-help interventions, 205–206 and suicide, 115
statistics, 201–202 vending machine game, 158
Social Interaction Anxiety Scale, 96 victim game, 157
Social learning theory, 111 woe-is-me game, 157
Social phobia, 93 Substance Abuse Mental Health Services Administration
Social-skills training, 55 (SAMHSA), 216
Social support, 12 Substance abuse treatment, 156
in adherence to medications, 359 abstinence model, 150–151
in diabetes treatment, 335 aftercare, 154
and suicide, 112 axioms, 155
Somaticizers, 162 behavioral model, 150
Somatization, 12 challenges, 155–156
assignment of treatment, 167–168 confronting denials in, 157–159
extreme outreach method, 167 group vs. individual therapy, 153–154
extreme protocol, 170 inpatient vs. outpatient care, 151–152
Fort Bragg study, 172–173 leveraging blackouts in, 156–157
392 • Index
medical model, 150 T

mobilization of rage in, 156
motivation in, 154–155 Take Charge! treatment protocol, 332–333
preaddictive group, 155 Team performance skills, 34, 43–45
Substance intoxication, 88 Team relationship, 30
Substance withdrawal, 88 Temperature biofeedback, 304
Suggestibility, 277, 282, 283 Tension headache; see also Headaches
Suicide, 109–110 characteristics of, 294
age risk, 112 epidemiology of, 294–295
and alcohol abuse, 115 responses to nonpharmacological treatment, 305
assessment factors, 116–117 Tenuate, 265
chronic pain and medical illness, 112 Therapeutic alliance, 30
clinical examples, 122–123 Therapist-guided change, 28–29
demographics of, 111–115 Therapy, 30–31
and depression, 112–113 Total body conductivity (TOBEC), 257
and drug abuse, 115 Train-the-trainer dissemination mode, 46
and emotion dysregulation, 120–121 Trauma, 114, 130–132
family risk factors, 111–112 Traumatic Life Events Questionnaire (TLEQ),
genetic factors, 112 134–135
hospitalization as treatment, 118–119 Tumors, 237
interventive assessment, 119–120, 122–123
models of, 110–111
vs. parasuicide, 115–116
and psychiatric disorders, 113–115
U
psychological risk factors, 113, 123–124
Ultrasound imaging, 257
risk assessment, 117–119, 122–123
Undiagnosed psychological problem pathway, 12
social risk factors, 111
University of Rhode Island Change Assessment Scale
staff issues, 121–122
(URICA), 260
statistics, 109–110
Support groups, 228
Supportive discussion, 246
Surgery and primary care, 277–279
V
Surgical preparation, 273–274
Vapor inhalers, 203–204
and anxiety, 280–281
Vending machine game, 158
assessment of, 289
Vertical integration programs, 62–63
communication in, 285
Victim game, 157
and coping style, 281
Video training sessions, 24
cost savings in, 275
Vietnam veterans, 131
effectiveness of, 276–277
as empirically supported treatment, 274–275
included population in, 286–287
interventions for, 279 W
limited practice of, 275–276
logical consequences, 277 Waist circumference, 257
and medical history, 281 West-Haven Tale Multidimensional Pain
medical offices, 284 Inventory, 318
obstacles, 288 Widows and suicide, 111
presurgical preparation form, 286 Withdrawal, 150
in primary care, 277–279 Woe-is-me game, 157
research, 288–289
selection of treatment options, 282–284
self-efficacy in, 279–280 X
starting, 284–285
suggestibility in, 277, 282 Xenical, 265–266
timing in, 279–280
Symptom Checklist-90, 341
Symptom Driven Diagnostic System for Primary Care Z
(SDDS-PC), 97
Synar Regulation, 216 Zoloft, 83

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RT9467_half title page 11/3/04 9:38 AM Page 1

NEW YORK AND HOVE

Published in Great Britain by

Copyright © 2005 by Taylor & Francis Group, a Division of T&F Informa.

Brunner-Routledge is an imprint of the Taylor & Francis Group.

Library of Congress Cataloging-in-Publication Data

About the Editors ix

Introduction The Case for Integrated Care: Coordinating Behavioral

Chapter 1 Training Behavioral Health and Primary Care Providers for

Chapter 2 Adapting Empirically Supported Treatments to the Primary

Chapter 3 The Role of the Behavioral Health-Care Specialist in the

Chapter 4 Anxiety Disorders in Primary Care 87

Chapter 6 Integrating PTSD Services: The Primary Behavioral

Chapter 7 Identification and Treatment of Substance Abuse in

Chapter 8 Identifying and Treating the Somatizer: Integrated Care’s

Chapter 9 Treating Attention Deficit Hyperactivity Disorder and

Chapter 10 Providing Integrated Care for Smoking Cessation 201

Chapter 11 Infertility 221

Chapter 12 The Integration of Psychosocial Interventions

Chapter 13 Managing Obesity in Primary Care 253

Chapter 14 As Precise as the Scalpel’s Cut … Sort of: Psychological and

Chapter 15 Assessment and Treatment of Chronic Benign Headache

Chapter 16 Addressing Chronic Pain in Primary Care Settings 315

Chapter 17 Psychosocial Interventions With Type 1 and 2

Chapter 18 Increasing Medication Adherence in Chronic Illnesses:

Chapter 19 The Integrated Management of Adult Asthma 367

About the Editors

Nicholas A. Cummings, Ph.D., Sc.D., is a distinguished professor in the Department of Psychology

Deborah A. Henderson, M.S., is a doctoral candidate in clinical psychology at the University of

Edward B. Blanchard, Ph.D., is distinguished professor of psychology at SUNY–Albany and is an

Gregory A. Fabiano, M.A., is a clinical psychology graduate student at SUNY–Buffalo. Current

Kyle E. Ferguson is a doctoral student in clinical psychology at the University of Nevada–Reno.

Eric R. Levensky, M.A., is a doctoral candidate in clinical psychology at the University of

Richard C. Robinson, Ph.D., is an assistant professor at the University of Texas Southwestern

MICHELLE R. BYRD, WILLIAM T. O’DONOHUE, AND

The Context of Integrated Care

2 • Behavioral Integrative Care

Defining Integrated Care

1. Improved recognition of behavioral health needs in medical settings.

The Case for Integrated Care • 3

4 • Behavioral Integrative Care

The Case for Integrated Care • 5

Rationale for Integrated Care Model

Integrated Care Treats Psychological Disorders Where Treatment Is Sought

6 • Behavioral Integrative Care

Integrated Care Provides More Service to More People

Integrated Care May Improve Treatment of Physical Problems

The Case for Integrated Care • 7

Medical Cost Offset

8 • Behavioral Integrative Care

$200 Year prior to study

$100 Year after study

$500 Year prior to study

Year after study

Targeted, Other Mental No Mental

The Case for Integrated Care • 9

Average Medical Utilization

10 • Behavioral Integrative Care

Summary of Rationale for Integrated Care

Implementation of Integrated Models of Care

The Case for Integrated Care • 11

12 • Behavioral Integrative Care

The Case for Integrated Care • 13